The locomotor system
C. Simon Herrington in Muir's Textbook of Pathology, 2020
Giant cell tumour principally affects individuals aged between 20 and 40 years. Most tumours occur in the long bones with half in the distal femur and proximal tibia. Almost all arise in the bone end, although extension into the metaphysis is often seen. Radiologically a giant cell tumour is a lytic lesion that often causes eccentric expansion, and may be covered by a shell of subperiosteal bone or extend into the soft tissue. Pathological fracture often occurs. Grossly the tumour is soft and red with areas of haemorrhage and necrosis. On microscopy, ovoid mononuclear tumour cells are interspersed with very large reactive osteoclasts (Figure 13.19). The mononuclear cells are the neoplastic cell population and they express receptor activator of nuclear factor kappa-B ligand (RANKL). Giant cell tumour has recently been associated with mutations in the H3F3A gene.
Management of Conditions and Symptoms
Amy J. Litterini, Christopher M. Wilson in Physical Activity and Rehabilitation in Life-threatening Illness, 2021
In the application of physical activity, exercise, and rehabilitation, metastatic bone lesions are a commonly encountered and expected issue that must be carefully addressed and understood. In addition to primary bone cancers and metastatic disease, osteoporosis and osteopenia also pose a risk of pathologic fracture. Depending on the therapist’s practice setting, there may be a dearth of information beyond a passing mention of osteoporosis, osteopenia, or metastatic disease. As physician team members are often focused on saving their patient’s life and optimizing medical and emotional quality of life, the same level of information to establish bony stability may not be available as compared to the interest clinicians who administer physical activity. In these cases where there is a concern for bone stability, advocacy for the patient, and facilitating a diagnostic workup is important to comprehensively manage the individual’s physical activity status. If a fall or injury occurred in a high-risk pathologic fracture scenario, it can substantially worsen the remaining quality of life. Conversely, if the pathologic fracture risk is small and the therapist resorts to excessively conservative treatments, their patient may not be able to enjoy an optimal quality of life as their physical status was unnecessarily restricted.
Bone lymphoma
Franco Cavalli, Harald Stein, Emanuele Zucca in Extranodal Lymphomas, 2008
The commonest presenting feature is pain (80–95%), swelling is present in 30–40%, and 15–20% present with a pathological fracture. Spinal cord compression was noted in 14% of patients in a recent larger series.45 B symptoms are relatively uncommon, at 5–15%. Lactate dehydrogenase (LDH) levels may be elevated in around 30% of patients. A modified IPI (International Prognostic Index) scoring system can be applied to PBL, and patients are often well spread across the prognostic categories. The majority of patients present with unifocal disease. However, it is possible to get multifocal disease both within a single bone (monostotic disease) and in different bones (polyostotic disease). In the case of multifocal, monostotic disease, it can be difficult to distinguish between disease that has permeated the bone extensively and continuously, and those with multiple, discontinuous lesions. In around 20% of patients, soft tissue disease may also be present, most commonly in the form of regional nodes, although other nodes and other soft tissues can be affected. Median tumor sizes are 5–10 cm, but vary widely from 1 to 30 cm. Extraosseous extension is present in around 50% of cases and can make it difficult to be certain that the disease has arisen in bone rather than adjacent lymph nodes. An example is presented in Figure 16.1, in which a patient presented with pain above the hip, and films revealed a tumor mass in the right ilium. Although the tumor mass predominantly affected areas where pelvic lymph nodes might be expected to give rise to nodal masses, the presence of widespread bony disease in other areas indicated that the tumor was likely to be exhibiting a tendency to occur in bone.
Spinal metastasis with neurologic deficits
Published in Acta Orthopaedica, 2018
Panagiotis Tsagozis, Henrik C F Bauer
Mean age at referral was 68 (28–89) years and mean follow-up was 15 months. At last follow-up 3 patients were still alive. The majority of patients in the S-group (n = 34) had prostate cancer, whereas 12 had lung cancer, 7 breast cancer, 5 renal cancer, and 18 had other malignancies. In the M-group, 15 patients had prostate cancer, 6 myeloma, 4 breast cancer, 3 lung cancer, and 2 had other malignancies. 94 patients presented with compression of the thoracic spine, 19 of the lumbar, and 3 of the cervical spine. Imaging was by MRI or CT. A pathological fracture was documented in 21 patients. 9% of the patients had a Frankel A score at admittance, 9% Frankel B, 26% Frankel C, 35% Frankel D, and 22% Frankel E. Of the patients belonging to the M-group, 20 had Frankel-D status at diagnosis and 20 only minor deficits, which were best classified to the Frankel E grade. Of patients in the S-group, 10 had Frankel A status at diagnosis, 10 Frankel B, 28 Frankel C, 22 Frankel D and 6 Frankel E. All but 5 patients had had postoperative radiotherapy (3 because of poor general condition and 2 because adjuvant treatment relied on systemic chemotherapy). Postoperative radiotherapy was given after wound healing (3–6 weeks). In half of the patients the given dose was 20 Gy (4 Gy x 5), in 20% 16 Gy (8 Gy x 2), in 18% the dose exceeded 20 Gy (the most common being 30 Gy given in 10 fractions) and in 12% of cases a single dose of 8 Gy was given.
“Pathological” fractures in spinal cord injuries and disorders: Insight into International classification of diseases, ninth revision coding
Published in The Journal of Spinal Cord Medicine, 2023
Rachel Elam, James Doan, Frances Weaver, Cara Ray, Scott Miskevics, Beverly Gonzalez, William Obremskey, Laura Carbone
Epidemiological studies of osteoporosis utilizing administrative data in persons with spinal cord injury or disorder (SCID) who sustain lower extremity fractures have also commonly excluded pathological fractures.7–10 Although the rationale for this is often not explicitly stated, the implication is that a pathological fracture is secondary to a localized process (such as malignancy) rather than osteoporosis. However, it is not known whether these fractures are indeed osteoporotic, and therefore should be included, as provider patterns for allocation of ICD-9 diagnosis codes in the setting of osteoporotic fractures in patients with SCID are poorly characterized. We hypothesized that some Veterans with SCID with a diagnosis of a lower extremity pathological fracture identified from administrative databases would have no apparent metastatic cancer to bone or other localized disorder of bone. Moreover, the interpretation of what constitutes a pathological fracture to physicians caring for patients with SCID who sustain a fracture was explored by surveying an expert panel.
Economic burden of skeletal-related events in patients with multiple myeloma: analysis of US commercial claims database
Published in Journal of Medical Economics, 2018
Debajyoti Bhowmik, Dionne M. Hines, Michele Intorcia, Rolin L. Wade
SREs were identified by the presence of at least one diagnosis or procedure code indicative of PF, SCC, RAD, or SURG. A hierarchy was used to classify SRE codes that were recorded within a 21-day window. Specifically, if surgery or radiation to bone occurred within 21 days after a pathological fracture, those procedures were assumed to be treatment for the fracture, and the SRE was classified as pathological fracture. Similar logic was used to identify and classify surgical and radiation treatments that occurred within 21 days after a spinal cord compression. Finally, if a pathological fracture occurred within 21 days after a spinal cord compression, the SRE was coded as a spinal cord compression. Outside of this hierarchy, SRE codes that occurred at least 21 days apart were considered separate, distinct SREs7.
Related Knowledge Centers
- Bone Fracture
- Osteoporosis
- Cancer
- Infection
- Osteomyelitis
- Bone Cyst
- Osteomalacia
- Paget'S Disease of Bone
- Osteitis
- Osteogenesis Imperfecta