Malignant tumor characterized by production of
osteoid by malignant cells.
composed of sarcomatous stroma & malignant
osteoblasts that directly form tumor osteoid ,
although fibrous or cartilagenous elements coexists
arises in the metaphysis of long bone where
normally growth is more active.
m.c primary malignancy of the bone
• most common malignant tumor of bone in
children & young adult
• accounts for 20% of primary malignacies of the
• incidence 1 to 3 per 1 million per year
all skeletal locations can be affected ; however,
most primary osteosarcomas occur at the sites of
the most rapid bone growth.
most common sites are
the distal end of femur
the proximal end of tibia
(accounts for more than 50 % of cases)
the proximal end of humerus
the proximal end of femur.
may affect any age.
Generally between 10- 25 yrs.
primary high-grade osteosarcoma - second decade
parosteal osteosarcoma - peak incidence in the
third and fourth decades.
secondary osteosarcomas - in older individuals
male > female
except parosteal osteosarcoma which is more
common in females
Oncogenic viruses like Harvey and Moloney
mouse sarcoma virus(RNA virus) and polyoma
and SV 40 (DNA virus)
Radiation exposure above 2000 rads with latent
period of 4 yrs.
Chemical agents like 20-methyl
results from microinfarctions .
only about 25% of patients experience this
3)Swelling appears after a few days &
4) An antalgic limp
5) Great majority of patients do not have fever, wt loss,
cachexia, except for disease at primary site
consistency : variegated
skin stretched and shiny
local rise of temperature
pulmonary signs with metastasis
Situated in metaphysis of long bones (lower end
of femur,upper end of tibia and humerus)
Appears as large tumor with destruction of inner
cortex as it extends into subperiosteal space.
Stony hard to soft,gritty consistency
Color reflects its components-fibrous looks
Necrotic foci and areas of degeneration are seen
• ‘Mutton leg’
• Grayish white
• Edge stops at
• intercellular matrix
scanty/ considerable amount
• osteoclastic cell type – when
there is rapid destruction of
• cartilage cells-
begin in intramedullary location – break
through cortex - form a soft tissue mass.
osteoblastic/ fibroblastic / chondroblastic
osteoid production from tumor cells.
high grade spindle cell component.
RADIOGRAPH showing typical malignant features including permeative-motheaten
pattern of destruction, irregular cortical destruction and aggressive (interrupted)
•Plain radiographs are most valuable tool for correct
•Most common is – aggressive lesion in the
metaphysis of long bone(90%).( 10% diaphyseal &
•Predominantly blastic / lytic
•Lesions are quite permeative & ill defined
•Codman’s triangle, Sunburst / hair on end
appearance may be seen.
Cloud-like bone formation in
Notice the aggressive, interrupted
Trabecular ossification pattern
in osteoid osteoma.
Notice osteolytic nidus (arrow).
Wide zone of transition indicates malignancy or infection or
An ill-defined border with a broad zone of transition is a sign of aggressive
growth It is a feature of malignant bone tumors.
There are two tumor-like lesions which may mimic a malignancy and have to be
included in the differential diagnosis. These are infections and eosinophilic
non-specific reaction and will occur whenever
the periosteum is irritated by a malignant
tumor, benign tumor, infection or trauma
two patterns of periosteal reaction:
a benign and
an aggressive type.
The periosteum is a membrane
several cell layers thick that covers
entire bone except area covered by
Besides covering the bone and
sharing some of its blood supply
with the bone, it also produces
bone when it is stimulated
With slow-growing lesions, the
periosteum has time to produce new
With rapidly growing lesions, the
periosteum cannot produce new bone
as fast. An interrupted pattern results,
which may be:
a thin shell of calcified new bone
one or more concentric shells of new bone
over the lesion, sometimes called lamellated
or "onion-skin" periosteal reaction.
If the lesion grows rapidly but
steadily, the periosteum will not
have enough time to lay down
even a thin shell of bone
In such cases, the tiny fibers that
connect the periosteum to the
bone (Sharpey's fibers) become
stretched out perpendicular to
When these fibers ossify, they
produce a pattern sometimes
called "sunburstsunburst" or "hair-on-hair-on-
endend" periosteal reaction,
depending of how much of the
bone is involved by the process.
A benign type of periosteal reaction is a thick, wavy and uniform
callus formation resulting from chronic irritation.
Benign periosteal reaction in an osteoid osteoma
Aggressive periosteal reaction
reaction and Codman's
Ewing sarcoma with
lamellated and focally
Infection with a
A)hair on end –
Anteroposterior and lateral radiographs of
proximal tibia with chondroblastic
the neoplastic bone appears amorphous .
used to evaluate the chest for pulmonary metastases.
approximately 10% to 20% of patients with
osteosarcoma present with radiographically detectable
metastases at diagnosis. most of these are in the lungs.
chest ct is superior to plain radiography in
demonstrating these metastases, and spiral ct is
superior to conventional ct for this purpose.
M R I
largely replaced ct as the optimal modality for
imaging the primary tumor.
demonstrates the degree of soft tissue extension
and the relationship of the extracompartmental
tumor to fascial planes and neurovascular
best feature is its ability to precisely evaluate the
extent of tumor in the medullary cavity.
occult skip metastases of 2 mm or more in long
bones are well seen on MRI
Anteroposterior view of proximal humerus with
MRI shows extent of tumor within bone and soft tissue
bone scan with technetium 99m shows a marked increase in the
uptake due to active formation of new tumor and host bone as
well as the vascularity of the lesion.
radionuclide bone scintigraphy is used to look for bony
metastases in the involved bone (skip metastases) and at other
mineralized metastases are more likely to be detected by bone
scans than are nonmineralized ones at extrapulmonary sites.
the intensity of the uptake increases with the vascularity of the
• gallium scans
are the most sensitive tests for locating
• positron emission tomography
• useful in
- planning the biopsy,
- evaluating the response to chemotherapy, and
helping to direct subsequent treatment.
single most important step in
- histological diagnosis and
- to plan type and extent of treatment.
- Less sampling error,
- provides the most tissue for additional diagnostic
studies, such as cytogenetics and flow cytometry.
- complication rates are high.
- can provide an accurate diagnosis in 90% of cases.
- the limited amount of tissue obtained may not be
excisional biopsy- done in benign tumors.
• may be 90% accurate at determining
malignancy; however, its accuracy at determining
specific tumor type is much lower.
• the absence of malignant cells on fine needle
aspiration is less reassuring than a negative
• Placement of the biopsy is a crucial decision because the
biopsy track needs to be excised en bloc with the
• Transverse incisions should be avoided because they
are extremely difficult or impossible to excise with the
•The deep incision should go through a single
muscle compartment rather than contaminating
an intermuscular plane
The periphery of a lesion usually contains the most
viable tissue and is the best tissue on which
diagnosis is based
If hole must be made in bone during biopsy, defect should be round to
minimize stress concentration, which otherwise could lead to
poorly performed biopsies.
Biopsy resulted in irregular defect in bone, which led to pathological fracture.
Transverse incisions should not be used. Multiple needle tracks contaminate quadriceps
Needle biopsy track
Drain site was not
placed in line with
Enneking System for Staging
Stage Grade Site Metastases
IA Low Intracompartmental None
IB Low Extracompartmental None
IIA High Intracompartmental None
IIB High Extracompartmental None
III Any Any Regional or distant
American Joint Committee on Cancer
System for Staging Soft-Tissue
Stage Grade Size Depth Metastases
I Low Any Any None
II Low ≤5 cm Any None
High >5 cm Superficial None
III High >5 cm Deep None
IV Any Any Any Regional or
CBC - usually normal
ESR - elevated, not specific.
ALP - elevated in osteosarcoma, reflecting
osteogenesis in the neoplastic tissue.
degree of elevation of this enzyme depend on
activity of the neoplastic osteoblasts within the
size of the tumor.
an elevated ALP level has been associated with a
the course of osteosarcoma can be monitored by serial
determination of serum alkaline phosphatase levels.
following ablation of the tumor, the enzyme level falls to near
normal; it rises with the development of metastases and with
in some studies, the LDH level has been shown to be of
an ELEVATED LDH level is associated with a
an intermediate-grade chondroblastic
osteosarcoma that arises on the surface of the
the most common locations are the diaphysis of
femur and tibia
it occurs in a slightly older and broader age group.
strands of osteoid-producing spindle cells
radiating between lobules of cartilage.
low grade fibroblastic or juxtracortical
4 % of all osteosarcoma.
occurs at late age , females
arises from surface of the bone
it invade the medullary cavity in the late stages
it has a peculiar tendency to occur as a lobulated
ossified mass on the posterior aspect of the distal
• it usually appears on the surface ( rather than
intracortically ) producing large homogeonenous
lobulated new bone outside the bone shell and
into the soft tissue- often palpable.
trabeculae of malignant bone
& osteoid tissue with
definite malignant connective
encapsulated by fibrous
shows a medullary cavity containing marrow in
continuity with the medullary canal of the
• myositis ossificans-
the ossification in myositis ossificans is more
mature at the periphery of the lesion, whereas the
center of a parosteal osteosarcoma is more
• rare type
• an indolent course with relatively benign features on
• mistaken radiographically and histologically for an
osteoblastoma or fibrous dysplasia.
• located in an intramedullary location and erodes
through the cortex only very late.
slightly atypical spindle cells producing slightly
irregular osseous trabeculae.
GENERAL PROGNOSIS IS BETTER THAN
PRI. AMPUTATION – 50 – 70 % 5 YR
FOR SMALL LESIONS, EARLY WIDE
RESECTIONS SHOW 80 – 90 % LONG TERM
• least common type.
• an aggressive tumor arising on the outer aspect of
• radiographs show an invasive lesion with ill-defined
• the microscopic appearance is similar to
• in contrast to parosteal osteosarcoma, medullary
involvement is common at the time of diagnosis.
• purely lytic
• x-ray may show invasive lesion or ballooned out
appearance similar to ABC
• grossly , resembles a blood filled cyst with very
small solid portion
• on low power microscope it resembles ABC with
blood filled spaces separated by septa but high
power will reveal that cells in the septa are frankly
SMALL CELL OSTEOSARCOMA
high grade lesion
consists of blue cells resembling ewing’s
sarcoma or lymphoma
cytogenetic and immunohistochemistry
needed to differentiate them.
• rare in young but constitutes almost of the
osteosarcomas in pts. older then 50 yrs of age.
• most common factors associated with it are
1. paget disease
2. previous radiation treatment
• pagets osteosar. -6th – 8th
decade of life and
pelvis is the mc site.
• radiation osteos. occurs in pts who have been
treated with greater then 2500 cgy and occurs in
unusal locations like skull, spine, clavicle, ribs,
scapula and pelvis
a Resection of proximal tibia with typical features of osteosarcoma.
Mapping of the specimen is done in order to evaluate the response to given preop
chemotherapy. b Pretreatment biopsy of high-grade osteoblastic
osteosarcoma. c After treatment the tumor is replaced by a network
acellular mineralized bone indicating good response. d Active fracture callus
may show features resembling osteosarcoma but lack true anaplasia. e
Resection of lower leg showing a telangiectatic osteosarcoma in the
distal tibia. f Telangiectatic osteosarcoma resembles an aneurysmal bone
• ADJUVANT CHEMOTHERAPY -chemotherapy administered
postoperatively to treat presumed micrometastases.
• neoadjuvant chemotherapy chemotherapy administered before
surgical resection of the primary tumor
currently most orthopaedic oncologists favor preoperative
chemotherapy with the definitive procedure performed 3 to 4 weeks
after the last dose has been administered.
chemotherapy is restarted 2 weeks postoperatively if the wound has
chemotherapy drugs are most effective when the
tumor against which they are directed is small.
combinations of these drugs are more effective than
dosage, sequence of drugs, and schedule seem to be
important in achieving the maximal response.
all have toxicity for normal tissues
Advantages of neoadjuvant
chemotherapy over adjuvant
chemotherapy. Preoperative chemotherapy frequently causes regression
of the primary tumor, making a successful limb salvage
. Neoadjuvant chemotherapy followed by surgical
resection allows for histological evaluation of the
effectiveness of treatment.
This is one of the most valuable prognostic indicators of
successful long-term outcome.
Preoperative chemotherapy theoretically may
decrease the spread of tumor cells at the time of
neoadjuvant chemotherapy usually can be started
immediately, effectively treating
micrometastases at the earliest time possible.
Prevents tumor progression, which may occur
during any delay before surgery.
Glycoside antibiotic,binds to DNA and inhibits
Reversible and dose related are leukemia,transient
Dose-30 mg/sq mt BSA for 3 days,repeated every 4
Binds to di-hydro folate reductase and cessation
of DNA synthesis
Vincristine is given 2 mg/sq m I.V half an hour
before methotrexate as it promotes its uptake.
Methotrexate(1.5 gm/sq m) given as I.V infusion
over 6 hr.
Repeated every 2 weekly and dose is gradually
increased upto 7.5 gm/sq m
Toxic effects-bone marrow suppression,oral
mucositis,vomiting and transient elevation of liver
Doxorubicin and cisplatin therapy
Doxorubicin 25 mg/m2 IV on days 1-3 plus cisplatin 100
mg/m2 IV on day 1; repeat cycle every 21 days.
High-dose methotrexate, cisplatin, and
High-dose methotrexate 12 g/m2 IV given over 4h on
weeks 0, 1, 5, 6, 13, 14, 18,19, 23, 24, 37, and 38,
alternating with cisplatin 60 mg/m2 IV plus doxorubicin
37.5 mg/m2/day IV for 2d each on weeks 2, 7, 25, and 28.
High-dose methotrexate 12 g/m2 IV given over 4h on
weeks 3, 4, 8, 9, 13, 14, 18, 19,23, 24, 37, and 38,
alternating with cisplatin 60 mg/m2 IV plus doxorubicin
37.5 mg/m2/day IV for 2d each on weeks 5, 10, 25, and 28
2 cycles are given preoperatively, and 4 cycles are
usually given postoperatively
Requires administration of 15 mg leucovorin every 6h for
10 doses, starting 24h after initiation of high dose
Doxorubicin, cisplatin, ifosfamide, and high-
Ifosfamide 15 g/m2 plus methotrexate 12 g/m2plus
cisplatin 120 mg/m2plus doxorubicin 75 mg/m2
Postoperatively, patients receive 2 cycles of doxorubicin
90 mg/m2 and 3 cycles each of high-dose ifosfamide,
methotrexate, and cisplatin 120-150 mg/m2
Granulocyte colony-stimulating factor (G-CSF) support is
mandatory after the high-dose
PRINCIPLES OF SURGERY
Amputation versus Limb Salvage
Simon described four issues that must be considered whenever
contemplating limb salvage instead of an amputation, as
1. Would survival be affected by the treatment choice?
2. How do the short-term and long-term morbidity compare?
3. How would the function of a salvaged limb compare with
that of a prosthesis?
4. Are there any psychosocial consequences?
Irrespective of the method chosen to treat
osteosarcoma, the local tumor must be
completely excised with negative margins.
Although amputation is performed less
frequently than in the past, it remains the gold
standard of local control.
Indications for amputation
very young age, when limb length inequality would be a major
displaced pathologic fractures
large soft tissue masses involving neurovascular structures;
disease progression during chemotherapy;
local recurrence following limb salvage procedures.
In the upper extremity, attempt is made to preserve at least
hand function, because prosthetic replacements are not nearly
as good as a functional hand.
However, in the lower extremity, modern prosthetics are very
The level of amputation is determined by close scrutiny of
conventional radiographs, bone scans, and MRI.
The entire involved bone should be carefully evaluated by MRI
for skip metastases.
Most frequently, a wide cross-bone amputation is performed
rather than a radical amputation.
Exceptions might be a young child with a tibial osteosarcoma,
in whom knee disarticulation or above-knee amputation is
performed, or a hindfoot osteosarcoma requiring a below-knee
In very young children, residual limb overgrowth may be a
For below-knee amputations, this can be addressed by placing a
metacarpal plug in the distal tibial canal if the ipsilateral foot is
uninvolved by tumor.
Further, in very young children, the predicted length of the
residual limb at maturity may be very short if a growth plate is
For foot tumors, this can be addressed with a Syme's-type
amputation rather than a below-knee amputation
in proximal tibial lesions, a knee disarticulation may be
preferable to an above-knee amputation. These can be revised
at maturity if necessary for prosthetic fitting.
In “expendable” bones such as the clavicle, fibula, scapula, and
rib, resection without reconstruction can be considered.
Lesions of the radius and ulna are rare and can usually be
resected with minimal reconstruction or with fibular autografts
or allografts used for reconstruction.
Lesions of the hands and feet usually require amputation,
although ray amputation and partial amputations that preserve
some hand or foot function can sometimes be performed.
For lesions of the extremities that are deemed resectable, the
reconstruction can be complex and depends on the age of the
patient and the location of the tumor in reference to joints and
For most distal femoral and proximal tibial osteosarcomas, an
intracompartmental, intra-articular resection can be carried out.
The same is usually possible for lesions of the proximal
Reconstruction is achieved either with an osteoarticular
allograft or with a metallic prosthesis.
SALVAGE V/S AMPUTATIUON
more extensive surgical procedure
greater amount of morbidity
multiple future operations
periprosthetic fractures, prosthetic loosening,
allograft fracture, length discrepancy and late
after initial salvage 33% may later have
durability of reconstructions in long term
none of the reconstruction will give normal
ultimately choice depends upon patient’s
expectations and quality of life
Limb salvage –
is considered if there has been no progression of disease
locally or distantly and if the nerves and blood vessels are
free of tumor.
The most important issue is the ability to completely
resect the tumor with wide margins. The adjacent joint
and growth plates are assessed for tumor involvement.
The thickness of the soft tissue margin depends on the
type of tissue. A fascial margin is considered a more
substantial barrier to tumor spread than a similar
thickness of fat.
The resection should be planned with the goal of
achieving local control; reconstruction options are a
BARRIERS TO LIMB SALVAGE
poorly placed biopsy incision
major vascular involvement
encasement of major motor nerve
pathological fracture of involved bone
PHASES OF LIMB SALVAGE
RESECTION OF TUMOR
SOFT TISSUE AND MUSCLE TRANSFER
“THREE STRIKE RULE”
An intralesional margin --plane of surgical
dissection is within the tumor.
A marginal margin --closest plane of
dissection passes through the pseudocapsule.
Wide margins --plane of dissection is in
Radical margins --all the compartments
that contain tumor are removed en bloc
reconstructions currently, most musculoskeletal malignancies are
treated local resection and reconstruction.
goal of resection -- is to achieve wide surgical
margins if possible.
if this is impossible because of anatomical
constraints, a marginal resection combined with
adjuvant or neoadjuvant treatment (e.g., radiation
for a soft-tissue sarcoma) may be preferable to an
a marginal resection usually is adequate for most
reconstructions often are done on young patients
who are extremely active.
most reconstructions involve preserving a mobile
joint, for which these general options are available:
osteoarticular allograft reconstruction,
allograft-prosthesis composite reconstruction.
RECONSTRUCTION OF BONE DEFECT
A. SPONTANEOUS REPAIR
B. BONE GRAFTING
C. PROSTHETIC REPLACEMENT
D. COMBINATION OF ABOVE
A. is synonymous with fracture healing
B. small cavities produced by subtotal
C. defects following wide or marginal
excision(stability provided by remaining
bone and internal fixation)
tumor and bone are excised, majority of lesion is
removed from bone and remaining bone is
autoclaved for 20mins.
advantage is easy to procure and absence of
disadvantage is high incidence of nonunion,
fatigue failure and infection.
ability to replace ligaments, tendons, and
nonunion at the graft-host junction
degenerative joint disease
failure of ligament and tendon attachments.
Osteoarticular allografts may have a role as a
temporary measure to preserve an adjacent
physis in an immature patient
A proximal tibial osteoarticular allograft could be used
in an immature patient in an attempt to preserve the
distal femoral physis until skeletal maturity.
This could be converted later to an endoprosthetic
reconstruction when it becomes necessary.
may provide a long-term solution for some
avoid the complications of degenerative joint
disease and articular collapse, while still
preserving the ability to attach soft-tissue
structures directly, such as the patella tendon or
the hip abductors.
associated, however, with fatigue fracture,
infection, and nonunion at the graft-host
main indication for an allograft-
is an inadequate length of
remaining host bone to secure
the stem of an endoprosthesis.
provide long-term function for some patient
predictable immediate stability that allows for
quicker rehabilitation with immediate full weight
most endoprostheses are modular, allowing for
incremental limb lengthening as an immature
polyethylene wear is still a limiting factor for
fatigue fracture can occur at the rotating hinge, but
this too is easily replaceable.
fatigue fracture at the base of the intramedullary stem
where it attaches to the body of the prosthesis is more
for pediatric patients, future limb-length inequality
must be considered.
For patients who are near skeletal maturity
1) the reconstructed limb can be lengthened 1 cm at the initial
2)epiphysiodesis of the contralateral limb can be done at the
appropriate age to preserve limb-length equality (or to minimize
For younger patients,
amputation and rotationplasty
repiphysis expandable prosthesis
distal femur of 7-year-old girl with telangiectatic osteosarcoma. C,
Intraoperative photograph of resected specimen and custom Repiphysis
prosthesis. D, Intraoperative photograph after placement of prosthesis. E,
Repiphysis lengthening procedure. A, Locking mechanism (arrow) located.
B, The patient's leg is marked at this site. C, Electromagnetic coil is
placed around the patient's leg at the level of the locking mechanism. D,
Device activated. E and F, Preexpansion and postexpansion radiographs
• Rotationplasty is a procedure which allows the ankle to
substitute as the knee after 180 degree rotation of the limb.
•The original idea was conceived by Borggreve in 1927 to treat
a shortened lower limb with stiff knee after tuberculosis .
• Later popularized by Van Ness for management of proximal
focal femoral deficiency.
•Salzer in 1974 first used it for malignant tumors around the
Winkelmann classified rotationplasty into five groups, as
GROUP AI - lesion in distal femur.
the distal femur, knee joint, and proximal tibia
the lower leg is rotated 180 degrees;
tibia is joined to the remaining femur.
lesion in the proximal tibia.
distalmost femur, knee joint, and
proximal tibia are resected.
after rotation of 180 degrees, the distal
tibia is joined to the distal femur
• lesion in the proximal femur sparing the hip joint
and gluteal muscles.
• the upper femur and hip joint are resected, and the
leg is rotated 180 degrees.
• the distal femur is joined to the pelvis so that the
knee functions as the hip, and the ankle functions as
the knee .
GROUP BII —lesion in the proximal femur with
involvement of hip joint and contiguous soft
upper femur, hip joint, and lower hemipelvis are
resected, and the leg is rotated 180 degrees
remaining femur is joined to the remnant of the
ilium so that the knee functions as a hinged hip
joint and the ankle functions as the knee
GROUP BIII. – lesion in mid femur
the entire femur is resected.
the tibia is attached to the pelvis using
Long term prognosis
In patients who are long-term survivors after resection
of an extremity sarcoma, the probability of limb
survival is associated with
1) type of reconstruction
2) the location of the tumor.
Regarding prosthetic or allograft-prosthetic composite
location is the most important issue proximal
reconstructions generally outlasting more distal
(This is the inverse of the prognosis for overall patient survival,
with distal sarcomas having a better prognosis than proximal
Proximal femoral reconstructions generally outlast distal
femoral reconstructions, which generally outlast proximal tibial
Osteosarcoma is a relatively radioresistant malignancy.
For this reason, adjuvant chemotherapy and surgery have
been the mainstays of therapy.
Radiation therapy in the primary local control setting
should be reserved on a case-by-case basis for patients with
unresectable tumors and/or where margins of resection are
Typically these tumors involve the head and neck or spinal
For definitive radiation therapy, doses of 55–60 Gy are
given with conventional daily fractionation of 1.8 Gy.
modern radiation delivery techniques such as
intensity modulated radiation therapy and proton
beam therapy can be used.
Here the delivery of radiation to a target volume is
improved while scatter to surrounding organs can
Radiation therapy can be used as an effective
palliative measure particularly for painful bony
hollow catheters are implanted in the tumor bed at the
time of resection.
These catheters exit through the skin.
Postoperative radiographic evaluation and computer
calculations determine the optimal loading of the
catheters with radioisotopes.
High doses to be delivered to the target tissues.
The radiation levels fall off rapidly at the edges of the
field, sparing normal tissues
Brachytherapy catheters woven through polyglactin 910 (Vicryl) mesh to
help maintain proper spacing. Catheters placed along vessels and bone
(where margins were close) exiting through separate stab wounds.
1. radical dose levels of 7000 – 8000 rads.
2. distribute the dose according to probable disribution
of tumor cells.
3. exclude all normal tissue and biopsy scar.
with proper treatment
1. painless & nonedematous limb is attained
2. reduced incidence of fibrotic, atrophic limb
disadvantage -pathological # can occcur.
HIGH TUMOR DOSE OF 6000- 7000 RADS
(SOMETIMES 8000 RADS)
230 RADS/DAY OR 1000 RADS/WKLY.
WHEN BIOPSY IS DONE PRIOR TO FULL COURSE
OF IRRADIATION - BIOPSY SCAR SHOULD BE HELD
LESS THAN 2 CM. TO PREVENT RADIATION
NECROSIS & SKIN BREAKDOWN FOLLOWED BY
INF & HAEMORRHAGE.
NEEDLE BIOPSY SHOULD PREFERRED IN SUCH
liposomal muramyl tripeptide-phosphatidyl-
ethanolamine(mifamurtide)- an agent derived from
BCG that activates macrophages and increases
circulating cytokine levels.
Transtuzumab (Herceptin)- a monoclonal antibody
• most series report long-term survival of
60% to 75% for patients with high-grade
osteosarcoma without metastases at initial
presentation and 90% for low-grade
1. THE EXTENT OF THE DISEASE.(MOST
2. GRADE OF LESION
3. SIZE OF PRIMARY TUMOR
4. SKELETAL LOCATION
5. LOCAL RECURRENCE
• POOR PROGNOSTIC FACTORS
1. RAPID RELAPSE AFTER COMPLETION OF INITIAL
2. MANY, LARGE, UNRESECTABLE PULMONARY