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Osteosarcoma[2]

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Osteosarcoma[2]

  1. 1. Osteosarcoma 1 04/23/13
  2. 2. Overview 2DefinitionEpidemiologyPathogenesis Parosteal osteosarcomaSkeletal distribution Periosteal osteosarcomaClinical presentation High grade surfaceEvaluation osteosarcomaHigh grade osteosarcoma
  3. 3. Definition 32nd most common primary bone tumorMalignant tumor of mesenchymal originSpindle shaped cells that produce osteoid
  4. 4. Epidemiology 4Any age75% 12-25yrsModal incidence
  5. 5. Epidemiology 5Primary vs secondaryMale : femaleLi Fraunie syndrome
  6. 6. Pathogenesis 6UnknownModal incidence correlates with rapid bone growthRadiation exposureCancer survivorsRetinoblastoma
  7. 7. Skeletal distribution 7
  8. 8. Classification 8
  9. 9. Clinical Presentation 9Painful mass arising from boneTraumaMetastisize early in evolution  20% clinically detectable mets at dx
  10. 10. Evaluation 10Suspected diagnosis by hx and physicalSupported by xray
  11. 11. Plain Xray 11Lytic, sclerotic or mixedTypical characteristics of malignant tumorEnneking’s 4 questions
  12. 12. Initial Evaluation 12Define the extent of the diseaseLocallySystemically
  13. 13. Local 13CTMRI+/- Angiogram
  14. 14. CT14
  15. 15. MRI 15
  16. 16. Angio 16
  17. 17. Systemic 17Bone scanCT Chestlab
  18. 18. Classic High Grade Osteosarc 18Age, sexPresentationPhysical examBlood workPlain films  Site  size
  19. 19. Differential Dx 19Giant Cell TumorAneursymal Bone CystEwingsOsteoblastomaMetastasisLymphoma
  20. 20. Biopsy 20PrinciplesDx “high grade osteosarcoma”Now What??
  21. 21. Chemotherapy 21Micro metastasisWhat we have learned pre chemo (1970’s)Multi Institutional Osteosarcoma Study
  22. 22. Chemotherapy 22Chemo cannot control clinically detectable diseaseRadiation is ineffectiveLocal control is surgical
  23. 23. Chemotherapy 23Best protocol is subject of ongoing trialsDrugs  Doxorubicin  Cisplatin  Ifosfamide  Methotrexate  CyclophosphamideSide effects
  24. 24. Induction Chemotherapy 24Arose in conjunction with development of limb sparing surgeryIncrease survivalprognostic
  25. 25. Surgery 25Limb salvage the normNow safer procedureWide surgical margin
  26. 26. Surgical options 26Articular surface removed  Osteoarticular allograft replacement  Custom modular prosthesis  Allograft prosthesis composite  Allograft arthodesisSegment of diaphysis missing  Intercalary allograft
  27. 27. Surgery 27Young patient with open growth plate  Rotatioplasty  Conventional amputation
  28. 28. 28
  29. 29. Surgery 29Indication for amputation  Grossly displaced pathologic fracture  Encasement of neurovascular bundle  Tumor that enlarges during preop chemo and is adjacent to neurovascular bundle
  30. 30. Current Standard of Care 30Pretreatment radiologic stagingBx to confirm diagnosisPreoperative chemotherapyRepeat radiologic staging  (access chemo response, finalize surgical tx plan)Surgical resection with wide marginReconstruction using one of many technoquesPost op chemo based on preop response
  31. 31. Surface osteosarcoma 31ParostealPeriostealHigh grade surface osteosarcoma
  32. 32. Parosteal 325% of osteosarcomasPosterior metaphysis of distal femurSlow growing large ossified massConfused with osteochondromaString signLow gradetreatment
  33. 33. Parosteal Osteosarcoma 33
  34. 34. Parosteal Osteosarcoma 34
  35. 35. Periosteal Osteosarcoma 35Arises from surface of diaphysisCharacterized by bony spicule formation perpendicular to shaftSunburstLow gradeWide excision
  36. 36. High grade surface 36Very rare20-30’sAppearance as parosteal but histology high gradeTx as classic intermedullary

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