OSTEOSARCOMA

Gopal Singh
Lecturer
Oncology defined
Branch of medicine that deals with the
study, detection, treatment and
management of cancer and neoplasia

Root words
Neo- new
Plasia- growth
Plasm- substance
Trophy- size
+Oma- tumor
Statis- location



Root words
A- none
Ana- lack
Hyper- excessive
Meta- change
Dys- bad, deranged




Characteristics of Neoplasia
Uncontrolled growth of Abnormal cells
1. Benign
2. Malignant
3. Borderline

Characteristics of Neoplasia
Benign
Well-differentiated
Slow growth
Encapsulated
Non-invasive
Does NOT metastasize

Characteristics of Neoplasia
Malignant
Undifferentiated
Erratic and Uncontrolled Growth
Expansive and Invasive
Secretes abnormal proteins
Metastasizes
Classifications of primary tumours involving
bones
metastatic cancers are the most frequent malignant tumors found in
bone

Histological Types Benign Malignant
Hematopoietic (40%)

Myeloma
Malignant lymphoma
Chondrogenic (22%)

Osteochondroma
Chondroma
Chondroblastoma
Chondromyxoid fibroma
Chondrosarcoma
Dedifferentiated
chondrosarcoma

Osteogenic (19%)

Osteoid osteoma
Osteoblastoma
Osteosarcoma

Unknown origin (10%) Giant cell tumour

Ewing tumour
Giant cell tumour
Adamantinoma
Histiocytic origin
Fibrogenic
Notochordal
Vascular, Cystic, lipogenic
neurogenic
Fibrous histiocytoma
Fibroma
MFH
Fibrosarcoma
Chordoma

Age(probably the most important clinical clue).
Age group

Most common benign
lesions

Most common malignant
tumors

0 - 10

simple bone cyst
eosinophilic granuloma

Ewing's sarcoma
leukemic involvement
metastatic neuroblastoma

10 - 20

non-ossifying fibroma
fibrous dysplasia
simple bone cyst
aneurysmal bone cyst
osteochondroma (exostosis)
osteoid osteoma
osteoblastoma
chondroblastoma
chondromyxoid fibroma

osteosarcoma,
Ewing's sarcoma,
adamantinoma

20 - 40

enchondroma
giant cell tumor

chondrosarcoma

40 & above

osteoma

metastatic tumors
myeloma
leukemic involvement
chondrosarcoma
osteosarcoma (Paget's
associated)
MFH
chordoma

Defination
Osteosarcoma is the name given to a
heterogeneous group of malignant spindle cell
tumors that have as their common feature the
production of immature bone, also known as
OSTEOID.

Epidemiology
It is the second most common primary
malignancy of bone
The incidence is approximately 1-3 per 1
million per year.
Male>female

Epidemiology
Most common sites are the
Distal femur
Proximal tibia
Proximal humerus

Risk Factors/Etiology
The exact cause of osteosarcoma is
unknown
Rapid bone growth
Environmental factors (exposure to radiation
)
Known causative agents are divided into
Chemicals
Viruses
radiation
miscellaneous
Classification
Osteosarcomas are categorized as
primary or secondary.
Primary Osteosarcomas are
Conventional osteosarcoma,
Low-grade intramedullary osteosarcoma,
Parosteal osteosarcoma,
Periosteal osteosarcoma,
High-grade surface osteosarcoma,
Telangiectatic osteosarcoma, and
Small cell osteosarcoma
Classification .
Secondary osteosarcomas
Osteosarcomas occurring at the site of
another disease process
The most common are
Paget disease
Previous radiation treatment


Classification .
Other associated conditions are
Fibrous dysplasia,
Bone infarcts,
Osteochondromas,
Chronic osteomyelitis,


Clinical feature
Pain
The pain may be progressive for many
months, and initially be confused with
more common sources such as muscle
soreness, overuse injury or "growing
pains."

Night pain is an important clue to the true
diagnosis (25%)


Clinical feature
Swelling
Palpable mass is noted in up to 1/3 of
patients at the first visit
Limp
In smaller children, a limp may be the only
symptom
Restriction of movement of the adjacent
joint
Pathological Fracture


Lab: Investigation
Full blood count, ESR, CRP.
LDH
ALP (elevated levels at diagnosis signify
increased risk of pulmonary metastasis)
Platelet count
Electrolyte levels
Liver function tests
Renal function tests
Urinalysis


Radiology: Investigation
CT scanning
CT scanning of the chest is more sensitive than is plain
film radiography for assessing pulmonary metastases.

MRI
MRI of the primary lesion is the best method to assess
the extent of intramedullary disease as well as
associated soft-tissue masses and skip lesions.

Bone Scan
A bone scan should be obtained to look for skeletal
metastases or multi focal disease.

Others Investigation
Thallium scan
Monitor effects of chemotherapy
Detect local recurrence of tumor

Angiography
Detect vascular displacement and
determine relationship of vessels to the
tumor
Identify vascular anomalies
Estimate effects of chemotherapy.

Once all the initial imaging & lab exam has
been done biopsy is performed to conform
the diagnosis.

Biopsy
Biopsy
Principles of Biopsy:
A biopsy should be planned as carefully
as the definitive procedure.

Biopsy should be done only after complete
clinical, laboratory, and radiographic
examinations.

Biopsy
Transverse incisions should be avoided.
The deep incision should go through a
single muscle compartment.
Biopsy should be taken from the periphery
of a lesion as it usually contains the most
viable tissue.
The wound should be closed tightly in
layers.

Types of biopsy

Fine needle aspiration
Core needle biopsy
Open incisional biopsy

Staging
The staging system devised and
introduced by Enneking in 1980 is applies
to all musculoskeletal tumors.
Staging system are the
Histologic grade of the tumor
(low grade vs high grade)
Anatomic location of the tumor
intracompartmental vs extracompartmental
Absence or presence of metastatic disease
Staging ..
Stage I: Low grade tumors
I-A intra compartmental
I-B extra compartmental
Stage II: High grade tumors
II-A intra compartmental
II-B extra compartmental
Stage III: Any tumors with evidence of
metastasis

Staging
American Joint Committee on Cancer System
for Staging Bone Sarcomas

Based on grade & size of tumor and presence
of metastasis

Stage Grade Size Metastases
I-A Low 8 cm None
I-B Low >8 cm None
II-A High 8 cm None
II-B High >8 cm None
III Any Any Skip metastasis
IV-A Any Any Pulmonary metastases
IV-B Any Any Nonpulmonary metastases
Treatment
1. Radiological staging
2. Biopsy to confirm diagnosis
3. Preoperative chemotherapy
4. Repeat radiological staging
(access chemo response, finalize surgical tx plan)
5. Surgical resection with wide margin
6. Reconstruction using one of many
techniques
7. Post op chemo based on preop response

Treatment .
The drugs used most often to treat
osteosarcoma are:
Methotrexate with leucovorin (folinic acid)
Doxorubicin (Adriamycin)
Cisplatin or carboplatin
Etoposide
Ifosfamide
Cyclophosphamide
Actinomycin D (dactinomycin)
Bleomycin

Treatment ..
Some common combinations of drugs
include:

Cisplatin and Adriamycin (CA)
Vincristine, Methotrexate, Leucovorin &
Adriamycin
High-dose methotrexate, Adriamycin, and
cisplatin (sometimes with ifosfamide)
Dactinomycin, bleomycin and cyclophosphamide
Ifosfamide and Etoposide
frequency....... Repeat cycle every 21 days
Side effect
General side effects:
Nausea and vomiting,
Loss of appetite,
Hair loss,
Mouth sores.

Chemotherapy can damage the blood-
producing cells resulting in:

Increased chance of infection ( W B C)
Bleeding or bruising ( Platelets)
Fatigue or shortness of breath ( RBCs)

Side effect..
Side effects of specific drugs.
Ifosfamide and cyclophosphamide : hemorrhagic cystitis.
Cisplatin: neuropathy, nephropathy, ototoxicity.
High-dose methotrexate: leukoencephalopathy and liver or kidney
damage.
Doxorubicin (Adriamycin): can cause heart damage over time.

Long-term side effects:
Infertility
Heart damage
Developing a second cancer
(
Surgery
The main goal of surgery is to safely and
completely remove the tumor.
Historically, most patients had an amputation.
Wide resection & prosthetic knee replacement
Transfemoral amputation is common
Complication of surgery
Hematoma
Infection
Wound necrosis
Contracture
Pain


Ewings Sarcoma
Introduction
Identified in 1921 by James Ewing

Differed from osteogenic sarcoma

Different location

Poor survival: 5-10% at 5 years

Epidemiology
Incidence is 0.6 per million

Males > Females

Rare in blacks and Asians

Clinical Features
Pain most commonly (90%)
Swelling (70%)
Fever (20%)
Pathological fracture
Weight loss
Malaise

Clinical Features ..
Local warmth, inflammation
Pleural effusions
Neurological signs if spinal involvement

Investigation
ESR
LDH
Anemia
Leukocytosis


Investigation: Radiology
Site
Size
Effect on bone
Response of Bone
Matrix
Cortex
Soft tissue

Staging
Local and distal staging

Bone marrow aspirate

Pre-chemotherapy investigations

Biopsy


Staging
Location

Tumor Size

Metastases at diagnosis

Response to chemotherapy

Treatment
Multidisciplinary approach
Neoadjuvant chemotherapy
Surgery
Radiation



Nursing Intervention
Promote Nutrition
Serve food in ways to make it appealing
Provide small frequent meals
Avoids giving fluids while eating
Oral hygiene PRIOR to mealtime
Vitamin supplements



Nursing Intervention..
Relieve Pain
Mild pain- NSAIDS
Moderate pain- Weak opiods
Severe pain- Morphine
Administer analgesics round the clock with
additional dose for breakthrough pain

Nursing Intervention..
Decrease Fatigue
Plan daily activities to allow alternating rest
periods
Light exercise is encouraged
Small frequent meals




Nursing Intervention..
Improve body image
Therapeutic communication is essential
Encourage independence in self-care and
decision making
Offer cosmetic material like make-up and wigs

Nursing Intervention..
Assist in the grieving process
Some cancers are curable
Grieving can be due to loss of health, income,
sexuality, and body image
Answer and clarify information about cancer
and treatment options
Identify resource people
Refer to support groups




Nursing Intervention..
Manage Complication: Infection
Fever is the most important sign (38.3)
Administer prescribed antibiotics X
2weeks
Maintain aseptic technique
Avoid exposure to crowds
Avoid giving fresh fruits and veggie
Handwashing
Avoid frequent invasive procedures


Nursing Intervention..
Manage complication: septic shock
Monitor VS, BP, temp
Administer IV antibiotics
Administer supplemental O2

Nursing Intervention..
Manage Complication: Bleeding
Thrombocytopenia (<100,000) is the most
common cause
<20, 000 spontaneous bleeding
Use soft toothbrush
Use electric razor
Avoid frequent IM, IV, rectal and
catheterization
Soft foods and stool softeners