Osteosarcoma: A Detailed Review

Download Osteosarcoma: A Detailed Review

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It is a presentation covering all the important aspects of the 2nd most common tumor, osteosarcoma in extensive details.

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<ul><li>1.OSTEOSARCOMA</li></ul> <p>2. INTRODUCTION 20% OF ALL PRIMARY BONE TUMOR SECOND-MOST COMMON PRIMARY MALIGNANCY OF BONE INCIDENCE: 1 TO 3 PER MILLION PER YEAR MALE: FEMALE1.6:1(EXCEPT PAROSTEAL VARIETY) AGE: CONVENTIONAL2ND DECADE 3. SITE AROUD THE KNEE JT.(ARISING MAINLY FROM METAPHYSIS;INTRAMEDULLARY REGION) 52% --LOWER END OF FEMUR20%-- UPPER END OF TIBIA 9% -- UPPER END OF HUMERUS 4. PREDISPOSING FACTORS : RADIATION VIRAL INFECTION: PLYOMA VIRUS/HARVEY VIRUS CHEMICALS:BERYLLIUM 20-METHYL CHOLANTHRENE 5. CLINICAL FEATURES PRESENTING FEATURES: - PAIN(NIGHT PAIN) -SOMETIMES ONLY TIREDNESS &amp; LIMP -PALPABLE MASS -SKIN CONDITIONS TO BE EXAMINED CAREFULLY H/O TRAUMA SOMETIMES DRAWS ATTENTION 6. ASSOCIATED FEATURES EFFUSION &amp; SWELLING OF NEARBY JOINTS FEVER PALLOR &amp; CACHEXIA REGIONAL LN FEATURES ASSOCIATED WITH PULMONARY METASTASIS PATHOLOGICAL # 7. OSTEOSARCOMA 8. CONTD.DISTAL NEUROVASCULAR DEFICITS AND PRESSURE SYMPTOMS .MAY BE ASSOCIATED WITH 9. CLASSIFICATION PRIMARY OSTEOSARCOMA SECONDARY OSTEOSARCOMA 10. CLASSIFICATION: WHO (PRIMARY OSTEOSARCOMA) CENTRAL(MEDULLARY) SURFACE(PERIPHERAL) 11. CENTRAL(MEDULLARY) CONVENTIONAL TELANGIECTATIC INTRAOSSEOUS/INTAMEDULLARY (WELL-DIFFERENTIATED/LOW-GRADE) SMALL CELL OSTEOSARCOMA 12. SURFACE(PERIPHERAL) PAROSTEAL(LOW-GRADE) PERIOSTEAL(LOW TO INTERMEDIATE GRADE) HIGH-GRADE SURFACE OSTEOSARCOMA 13. SECONDARY OSTEOSARCOMA -PAGETS DISEASE -RADIATION -BENIGN PRE-EXISTING CONDITIONS [OSTEOCHONDROMA 14. SECONDARY OSTEOSARCOMA OLDER AGE GROUP PROGNOSIS POOR LONG HO DULL ACHING PAIN&amp;RECENT LYTIC DESTRUCTION 15. PATHOLOGY: MACROSCOPY Typical osteosarcoma presents as a large illdefined lesion in the metaphyseal region of the involved bone. It typically destroys cortex and frequently extends inwards marrow cavity and outwards into the adjacent soft tissue. 16. PATHOLOGY: MACROSCOPY Tumour often elevates periosteum to produce codmans triangle on radiograph. It also produces sunray appearance due to vessels which pass from the periosteum to the cortex &amp; along which bone is laid down &amp; some of the new bone may be reactionary 17. PATHOLOGY: MACROSCOPY LARGE ILL-DEFINED LESION IN THE METAPHYSEAL REGION OF LONG BONE LEG OF MUTTON APPEARANCE STONY-HARD TO SOFT AND GRITTY IN CONSISTENCY AREAS OF HAEMORRHAGE &amp; NECROSIS COLOUR: WHITE : YELLOW : BLUISH WHITE:FIBROBLASTIC OSTEOBLASTIC CARTILAGENOUS 18. CONTD CODMANS TRIANGLE ---DUE TO SUBPERIOSTEAL NEW BONE FORMATION SUNRAY APPEARANCE ---DUE TO BONE DEPOSITION IN SUB-PERIOSTEAL SPACE ALONG THE VESSELS 19. SUNRAY APPEARENCE 20. PATHOLOGY:MICROSCOPY LICHTENSTENS CRITERIA TO IDENTIFY OSTEOSARCOMA : 1)SARCOMATOUS STROMA 2)SPINDLE CELLS. 3) DIRECT FORMATION OF NEOPLASTIC OSTEOID AND BONE. 21. PATHOLOGY:MICROSCOPY Hallmark of osteosarcoma is the formation of osteoid by malignant mesenchymal cells . The neoplastic mesenchymal cells in between osteoid &amp; cartilage elements may be spindle shaped and pleomorphic with bizarre hyperchromatic nuclei and frequent mitotic figures. Giant cells may be present. 22. RADIOLOGIC INVESTIGATIONS PLAIN RADIOGRAPH(X-RAY) CT SCAN MRI SCAN BONE SCAN 23. RADIOLOGY ARISES IN THE METAPHYSIAL REGION OF A LONG BONE OUTGROWS FROM THE MEDULLARY CANAL TO EXTRASKELETAL REGION DISPLAYS REPRESENTATIVE FEATURES OF A MALIGNANT LESION- PERMEATIVE GROWTH PATTERN/INDISTINCT MARGINS/CORTICAL EROSION 24. RADIOLOGY.. PERIOSTEAL REACTION WITH FORMATION OF CODMANS TRIANGLE/SUNBURST APPEARANCE WIDE VARIETY OF RADIOGRAPHIC APPEARANCE LIKE BONE CYST 25. RADIOLOGY.. CT SCAN AND MRI SCAN ARE NOT AS INSTRUMENTAL AS PLAIN RADIOGRAPH BONE SCAN IS USEFUL TO DETECT METASTASIS 26. RADIOLOGY..MRI SCAN EXCELLENT FOR DESCRIBING LESIONS IN THE MARROW CAVITY HELPFUL TO DETERMINE THE LEVEL OF RESECTION USEFUL FOR SCREENING SKIP LESIONS CAN DETECT MEDULLARY INVASION IN CASE OF JUXTACORTICAL TUMORS CAN DETECT EPIPHYSEAL INVOLVEMENT AND PENETRATION OF PHYSEAL CARTILAGE 27. DIAGNOSIS HISTORY CLINICAL EXAMINATION HAEMATOLOGY RADIOLOGICAL INVESTIGATIONS HISTOPATHOLOGIC EXAMINATION 28. MANAGEMENT: MULTIDISCIPLINARY APPROACH PRIMARY CARE PHYSICIAN ORTHOPAEDIC SURGEON RADIATION ONCOLOGIST PATHOLOGIST PHYSIOTHERAPIST REHABILITATION SPECIALIST SOCIAL WORKERS &amp; OTHERS 29. TREATMENT OPTIONS CHEMOTHERAPY SURGERY RADIOTHERAPY 30. CHEMOTHERAPY Introduction of systemic chemotherapy has dramatically improved survival rates. Before the routine use of chemotherapy treatment was immediate wide or radical amputation 80% patients died of metastasis eventually, though metastasis was not evident on presentation. 31. CHEMOTHERAPY NEO-ADJUVANT CHEMOTHERAPY: CT ADMINISTERED BEFORE THE SURGICAL RESECTION OF PRIMARY TUMOUR ADJUVANT CHEMOTHERAPY: CT ADMINISTERED POSTOPERATIVELY TO TREAT PRESUMED MICRO-METASTASIS 32. NEO-ADJUVANT CHEMOTHERAPY IT SHRINKS THE TUMOUR MASS , MAKING IT EASIER FOR OPERATION IT DECREASES THE SPREAD OF TUMOUR CELLS DURING SURGERY, T/T AGAINST POTENTIAL MICRO-METASTASIS STARTED IMMEDIATELY, (IT ALSO GIVES IDEA ABOUT RESPONSIVENESS &amp; EFFECTIVENESS OF THE CHEMOTHERAPEUTIC AGENT TO THE TUMOUR) 33. NEO-ADJUVANT CHEMOTHERAPY DISADVANTAGES IT MAY INCREASE PERI-OPERATIVE COMPLICATIONS(DELAYED WOUND HEALING, INFECTION) NAUSEA, VOMITING AND OTHER TOXICITIES MAY CAUSE DELAY IN SURGERY. 34. MANAGEMENT LOW GRADE OSTEOSARCOMA-- TREATED BY SURGERY ALONE. HIGH GRADE OSTEOSARCOMA-- TREATED BY NEO-ADJUVANT CHEMOTHERAPY SURGERY ADJUVANT CHEMOTHERAPY, 35. MANAGEMENT AFTER INDUCTION OF CHEMOTHERAPY(LASTING ABOUT 2 MONTHS) SURGICAL RESECTION IS TO BE CARRIED OUT. SURGERY IS CONTEMPLATED 3-4 WEEKS AFTER LAST DOSE OF CHEMOTHERAPEUTIC AGENT ADJUVANT CHEMOTHERAPY AGAIN STARTED 2 WEEKS AFTER OPERATION 36. COMMON AGENTS USED DOXORUBICIN 60-75 MG/M CARDIOTOXICITY, CISPLATIN -- 50-100 MG /M NEPHROTOXICITY VINCRISTINE -- 1.5 MG /M,WEEKLY PERIPHERAL NEUROPATHY METHOTREXATE 500-1000 MG/M IV MEGALOBLASTIC ANAEMIA, PANCYTOPENIA 37. CONTD CYCLOPHOSPHAMIDE &amp; IFOSFAMIDE -- 1-1.5 G/M B S A HAEMORRHAGIC CYSTITIS DACARBAZINE 250MG/MBSA FLU LIKE SYNDROME DACTINOMYCIN ERYTHEMA MYELOSUPPRESION 38. CONTD ROUTE OF ADMINISTRATION INTRAVENOUS ORAL &amp; INTRAMUSCULAR INTRA ARTERIAL 39. INTRA-ARTERIAL ADM OF CHEMOTHERAPY HIGHER CYTOTOXIC CONC. DIRECTED AGAINST TARGET TISSUE CISPLATIN MOST SUCCESSFUL AGENT INFLUENCING FACTORS PRETREATMENT ANGIOGRAPHY, CATHETER PLACEMENT, 40. RESPONSE TO PREOPERATIVE CHEMOTHERAPY ASSESSED BY CLINICAL RADIOGRAPHIC ANGIOGRAPHIC PATHOLOGICAL PARAMETERS 41. RADIATION THERAPY ROLE OF RADIOTHERAPY IS LIMITED IN THE TREATMENT OF OSTEO-SARCOMA --A RELATIVELY RADIO-RESISTANT TUMOR. RADIATION THERAPY CAN PALLIATE PAIN FROM LOCAL RECURRENCE AND PREVENT NEED FOR AMPUTATION IN PATIENTS WHO ARE PRESENTED WITH DISTANT METASTASIS 42. RADIATION THERAPY INDICATIONS POST-OPERATIVE -- WHERE SURGICAL MARGIN IS INVOLVED PALLIATION OF PAIN FROM PRIMARY TUMOUR IN THE PRESENCE OF METASTATIC DISEASE RADICAL TREATMENT OF INOPERABLE SITES (SKULL, VERTEBRA, ILIUM, SACRUM) BILATERAL LUNG IRRADIATION IN PULMONARY METASTASIS 43. RADIATION THERAPY EXTERNAL BEAM RADIATION BY LINEAR ACCELERETER. BRACHYTHERAPY LIMITED ROLE IORT SINGLE DOSE,IN SPECIALLY PREPARED OT 44. RADIATION THERAPY AC. SIDE EFFECTS SKIN REACTION MILD FATIGUE ANOREXIA ALTERED SLEEP &amp; REST CYCLE LATE EFFECTS LYMPHATIC &amp; VASCULAR OBST. OSTEO-NECROSIS JOINT STIFFNESS RADIATION INDUCED SARCOMAS 45. SURGERY SURGERY IS THE MAINSTAY OF THERAPY LIMB SACRIFICING SURGERY OR LIMB SALVAGING SURGERY ? 46. PRINCIPLES OF SURGERY CHOICE BETWEEN LIMB SALVAGE SURGERY AND AMPUTATION MUST BE MADE ON THE BASIS OF THE EXPECTATIONS AND DESIRES OF THE INDIVIDUAL PATIENT AND THE FAMILY. 47. PRINCIPLES OF SURGERY POINTS TO BE STRESSED SURVIVAL AFTER THE PROCEDURES SHORT AND LONG TERM MORBIDITY FUNCTION OF SALVAGED LIMB COMPARED TO PROSTHETICS PSYCHOSOCIAL CONSEQUENCES 48. PRINCIPLES OF SURGERY ADVANCES IN DIAGNOSTIC IMAGING CHEMOTHERAPY (NEO-ADJUVANT CHEMOTHERAPY) SURGICAL TECHNIQUES .HAVE MADE LIMB SALVAGE SURGERY A REASONABLE OPTION 49. LIMB SALVAGE SURGERY SURGICAL PROCEDURES DESIGNED TO ACCOMPLISH REMOVAL OF MALIGNANT TUMOURS &amp; RECONSTRUCTION OF THE LIMB WITH AN ACCEPTABLE ONCOLOGIC, FUNCTIONAL &amp; COSMETIC RESULTS. 50. LIMB SALVAGE SURGERY NEW SURGICAL TECHNIQUES. PROGNOSIS IMPROVED GREATLY. 51. LIMB SALVAGE SURGERY THREE IMPORTANT DEVELOPMENTS 1. Improvement in chemotherapy In early 70s methotrexate and adriamycin was introduced. 2. Improvement in imaging techniques development of CT &amp; MRI in late 70s. 3. Advances in micro- surgical techniques 52. GUIDELINES NO INVOLVEMENT OF MAJOR NEUROVASCULAR STRUCTURES WIDE RESECTION OF AFFECTED BONE WITH A NORMAL MUSCLE CUFF ALL AROUND EN-BLOCK REMOVAL OF ALL BIOPSY SITES &amp; CONTAMINATED TISSUE 53. GUIDELINES (contd.) RESECTION OF BONE 3-4 CM BEYOND ABNORMAL UPTAKE RESECTION OF ADJOINING JOINT &amp; CAPSULE. ADEQUATE MOTOR RECONSTRUCTION ADEQUATE SOFT TISSUE COVERAGE. 54. SURGICAL MARGINS IN ONCOLOGY 55. METHODS BONE GRAFTING AUTOLOGUS GRAFT : VASCULARISED GRAFT ALLOGENIC GRAFT : BONE BANK ROTATIONPLASTY RESECTION/ARTHRODESIS PROSTHESIS COMPOSITE ALLOGRAFT PROSTHETIC COMPOSITES 56. CONTRAINDICATIONS DISPLACED PATHOLOGICAL FRACTUREINAPPROPRIATE BIOPSY SITEINFECTIONSKELETAL IMMATURITYMAJOR NEUROVASCULAR INVOLVEMENTEXTENSIVE MUSCLE INVOLVEMENT 57. LIMB SALVAGE SURGERY LIMB SALVAGE SURGERY HAS BECOME AN ACCEPTED STANDARD OF CARE FOR PATIENTS WITH SKELETAL MALIGNANCIES INCLUDING OSTEOSARCOMA MANY PATIENTS WHO ONCE WOULD HAVE HAD AN AMPUTATION ARE NOW HAVING THEIR LIMB SAVED 58. TREATMENT OF PULMONARY METASTASIS LOCAL RECURRENCE SECONDARY DISEASE 59. PRONOSTIC FACTORS EXTENT OF DISEASE AT THE TIME OF DIAGNOSIS GRADE OF THE LESION SIZE OF THE TUMOUR LOCATION OF THE TUMOUR PAGETS SARCOMA RADIATION INDUCED SARCOMA RADIATION INDUCED NECROSIS 60. THANK YOU </p>