Osteosarcoma

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Osteosarcoma

  1. 1. Osteosarcoma Paul Duffy
  2. 2. Overview <ul><li>Definition </li></ul><ul><li>Epidemiology </li></ul><ul><li>Pathogenesis </li></ul><ul><li>Skeletal distribution </li></ul><ul><li>Clinical presentation </li></ul><ul><li>Evaluation </li></ul><ul><li>High grade osteosarcoma </li></ul><ul><li>Parosteal osteosarcoma </li></ul><ul><li>Periosteal osteosarcoma </li></ul><ul><li>High grade surface osteosarcoma </li></ul>
  3. 3. Definition <ul><li>2 nd most common primary bone tumor </li></ul><ul><li>Malignant tumor of mesenchymal origin </li></ul><ul><li>Spindle shaped cells that produce osteoid </li></ul>
  4. 4. Epidemiology <ul><li>Any age </li></ul><ul><li>75% 12-25yrs </li></ul><ul><li>Modal incidence </li></ul>
  5. 5. Epidemiology <ul><li>Primary vs secondary </li></ul><ul><li>Male : female </li></ul><ul><li>Li Fraunie syndrome </li></ul>
  6. 6. Pathogenesis <ul><li>Unknown </li></ul><ul><li>Modal incidence correlates with rapid bone growth </li></ul><ul><li>Radiation exposure </li></ul><ul><li>Cancer survivors </li></ul><ul><li>Retinoblastoma </li></ul>
  7. 7. Skeletal distribution
  8. 8. Classification
  9. 9. Clinical Presentation <ul><li>Painful mass arising from bone </li></ul><ul><li>Trauma </li></ul><ul><li>Metastisize early in evolution </li></ul><ul><ul><li>20% clinically detectable mets at dx </li></ul></ul>
  10. 10. Evaluation <ul><li>Suspected diagnosis by hx and physical </li></ul><ul><li>Supported by xray </li></ul>
  11. 11. Plain Xray <ul><li>Lytic, sclerotic or mixed </li></ul><ul><li>Typical characteristics of malignant tumor </li></ul><ul><li>Enneking’s 4 questions </li></ul>
  12. 12. Initial Evaluation <ul><li>Define the extent of the disease </li></ul><ul><li>Locally </li></ul><ul><li>Systemically </li></ul>
  13. 13. Local <ul><li>CT </li></ul><ul><li>MRI </li></ul><ul><li>+/- Angiogram </li></ul>
  14. 14. CT
  15. 15. MRI
  16. 16. Angio
  17. 17. Systemic <ul><li>Bone scan </li></ul><ul><li>CT Chest </li></ul><ul><li>lab </li></ul>
  18. 18. Classic High Grade Osteosarc <ul><li>Age, sex </li></ul><ul><li>Presentation </li></ul><ul><li>Physical exam </li></ul><ul><li>Blood work </li></ul><ul><li>Plain films </li></ul><ul><ul><li>Site </li></ul></ul><ul><ul><li>size </li></ul></ul>
  19. 19. Differential Dx <ul><li>Giant Cell Tumor </li></ul><ul><li>Aneursymal Bone Cyst </li></ul><ul><li>Ewings </li></ul><ul><li>Osteoblastoma </li></ul><ul><li>Metastasis </li></ul><ul><li>Lymphoma </li></ul>
  20. 20. Biopsy <ul><li>Principles </li></ul><ul><li>Dx “high grade osteosarcoma” </li></ul><ul><li>Now What?? </li></ul>
  21. 21. Chemotherapy <ul><li>Micro metastasis </li></ul><ul><li>What we have learned pre chemo (1970’s) </li></ul><ul><li>Multi Institutional Osteosarcoma Study </li></ul>
  22. 22. Chemotherapy <ul><li>Chemo cannot control clinically detectable disease </li></ul><ul><li>Radiation is ineffective </li></ul><ul><li>Local control is surgical </li></ul>
  23. 23. Chemotherapy <ul><li>Best protocol is subject of ongoing trials </li></ul><ul><li>Drugs </li></ul><ul><ul><li>Doxorubicin </li></ul></ul><ul><ul><li>Cisplatin </li></ul></ul><ul><ul><li>Ifosfamide </li></ul></ul><ul><ul><li>Methotrexate </li></ul></ul><ul><ul><li>Cyclophosphamide </li></ul></ul><ul><li>Side effects </li></ul>
  24. 24. Induction Chemotherapy <ul><li>Arose in conjunction with development of limb sparing surgery </li></ul><ul><li>Increase survival </li></ul><ul><li>prognostic </li></ul>
  25. 25. Surgery <ul><li>Limb salvage the norm </li></ul><ul><li>Now safer procedure </li></ul><ul><li>Wide surgical margin </li></ul>
  26. 26. Surgical options <ul><li>Articular surface removed </li></ul><ul><ul><li>Osteoarticular allograft replacement </li></ul></ul><ul><ul><li>Custom modular prosthesis </li></ul></ul><ul><ul><li>Allograft prosthesis composite </li></ul></ul><ul><ul><li>Allograft arthodesis </li></ul></ul><ul><li>Segment of diaphysis missing </li></ul><ul><ul><li>Intercalary allograft </li></ul></ul>
  27. 27. Surgery <ul><li>Young patient with open growth plate </li></ul><ul><ul><li>Rotatioplasty </li></ul></ul><ul><ul><li>Conventional amputation </li></ul></ul>
  28. 29. Surgery <ul><li>Indication for amputation </li></ul><ul><ul><li>Grossly displaced pathologic fracture </li></ul></ul><ul><ul><li>Encasement of neurovascular bundle </li></ul></ul><ul><ul><li>Tumor that enlarges during preop chemo and is adjacent to neurovascular bundle </li></ul></ul>
  29. 30. Current Standard of Care <ul><li>Pretreatment radiologic staging </li></ul><ul><li>Bx to confirm diagnosis </li></ul><ul><li>Preoperative chemotherapy </li></ul><ul><li>Repeat radiologic staging </li></ul><ul><ul><li>(access chemo response, finalize surgical tx plan) </li></ul></ul><ul><li>Surgical resection with wide margin </li></ul><ul><li>Reconstruction using one of many technoques </li></ul><ul><li>Post op chemo based on preop response </li></ul>
  30. 31. Surface osteosarcoma <ul><li>Parosteal </li></ul><ul><li>Periosteal </li></ul><ul><li>High grade surface osteosarcoma </li></ul>
  31. 32. Parosteal <ul><li>5% of osteosarcomas </li></ul><ul><li>Posterior metaphysis of distal femur </li></ul><ul><li>Slow growing large ossified mass </li></ul><ul><li>Confused with osteochondroma </li></ul><ul><li>String sign </li></ul><ul><li>Low grade </li></ul><ul><li>treatment </li></ul>
  32. 33. Parosteal Osteosarcoma
  33. 34. Parosteal Osteosarcoma
  34. 35. Periosteal Osteosarcoma <ul><li>Arises from surface of diaphysis </li></ul><ul><li>Characterized by bony spicule formation perpendicular to shaft </li></ul><ul><li>Sunburst </li></ul><ul><li>Low grade </li></ul><ul><li>Wide excision </li></ul>
  35. 36. High grade surface <ul><li>Very rare </li></ul><ul><li>20-30’s </li></ul><ul><li>Appearance as parosteal but histology high grade </li></ul><ul><li>Tx as classic intermedullary </li></ul>

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