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osteosarcoma locally advanced
- 1. ο Presenter: Melsew.A COR2 Moderater: Dr Matheos .A Clinical oncologist and inernist Osteosarcoma
- 2. ο ο A case of a Patient ο Clinical Presentation ο Standard work up ο Principles of management ο Prognostic factors ο Follow up ο Case Critics Outlines of presentation
- 3. ο ο A 50 years old male and camera man patient come from AA presented with falling down accident of 3 days duration from standing position ο 3 months prior to his accident he has left leg pain and swelling . ο Otherwise he has no medical illness ,and trauma hx ο He has no hx of irradiation ο He has no cough ο He is refered from menilik hospital MRN 549475
- 4. ο ο GA ;acutely sick looking in pain ο VS BP 140/70,PR 114 ο Msk;posterior long leg gutter and 4x5cm swelling inside gutter ο ASST:left tibia pathologic fracture ο PLAN :was to do left leg x ray,CXR,MRI of left leg,OFT ο ON 28/4/2011 ο On 10/5/2011 ο Incisional biopsy and external fixation was done P/E ON 28/4/2011
- 5. ο ο Hx :same ο ECOG1 ο V/S: stable ο HEENT:pink conjuctiva and NIS ο P/E :there is 5x4cm hard immobile mas on left distal tibia In our OPD
- 6. ο ο CBC:normal ο Abdominopelvic U/S:normal ο OFT:normal ο Chest CT:normal Investigations
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- 11. ο ο ASST:High grade conventional osteosarcoma ο Plan :Neoajuvant cisplatin and adriamycine ο Mid cycle evaluation for surgery and then ajuvant cisplatin and adriamycin Cont..
- 12. ο Question ???
- 13. ο ο Most patients present with localized pain in the affected bone. ο Pain is usually of several months duration and may wax and wane. ο There may be associated soft tissue swelling or a palpable mass. ο Some patients present with pathologic fracture. ο Osteosarcoma has a predilection for involvement of the metaphysis of long bones. Clinical Presentation
- 14. ο ο The most common site of involvement is the knee (distal femur or proximal tibia), followed by the proximal humerus, mid and proximal femur, and then other bones. ο Although most patients have micrometastatic disease at the time of presentation, only 10% to 20% of patients present with clinical evident macro metastases. ο The lung is the most common site of metastatic involvement, followed by bone. Cont..
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- 22. ο ο Types: ο Fine needle aspiration ο Core needle biopsy ο Open incisional biopsy Biopsy
- 23. ο ο Surgery ο Chemotherapy ο radiotherapy Treatments of OS
- 24. ο ο The mainstay of surgical management is the complete en bloc resection of tumor. ο The extent of surgery have dramatically evolved over time, with an emphasis on more conservative, limb-sparing resections with maintenance of function rather than amputation. ο Neoadjuvant chemotherapy has played an important role in this evolution Surgery
- 25. ο ο For extremity lesions, limb preservation is preferred and can be accomplished in the majority of cases. ο Retrospective studies have shown equivalent results of limb-sparing surgery and amputation as long as adequate margins can be achieved cont.,β¦
- 26. ο ο 1 JBJS Classics 227 patients From26 institutions Limbs paring Procedure 73disarticulati on of the hip 39 above-the knee amputation 115 LR 9 7.8% SUR 67 58% Met 65 56% LR 0 0% SUR 21 53% MET 21 53% LR 8 10% SUR 40 54.7% MET 43 58.9 % PEPTS local recurrence Metastasis survival after a median length of follow-up of 5.5years
- 27. ο ο The Kaplan-Meier estimates of the percentage of patients who survived and the percentage of patients without recurrent disease showed no difference among the three surgical groups (Mantel-Cox test statistic: p = 0.8) ο It appears that, compared with above-the-knee amputation or disarticulation of the hip, the use of a limb salvage procedure for osteosarcoma of the distal end of the femur did not shorten the disease- free interval or compromise long-term survival. Cont.β¦
- 28. ο ο However, not all patients are candidates for more conservative surgery . ο Axial tumors, although much less common, pose a particular challenge because achieving complete surgical resection can be difficult. Contβ¦
- 29. ο ο Pelvic tumors typically require a hemipelvectomy for en bloc resection. ο Some patients can undergo resection of the hemipelvis with preservation of the extremity . ο This has a better functional outcome compared to an external hemipelvectomy, also referred to as a hindquarter amputation Cont..
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- 32. ο ο compromise between amputation and limb salvage ο most commonly used for osteosarcomas of the distal femur in skeletally immature patients ο It is a procedure where the neurovascular structures and distal aspect of the limb (leg) are retained Rotationplasty
- 33. ο ο For functional purposes, the distal segment is turned 180 degrees so that the ankle joint functions as a knee joint, ο thus converting an above-knee to a below-knee amputation in order for prosthetic use to be maximized Contβ¦
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- 36. ο ο Contraindications to limb-sparing surgery include; ο nerve or vascular encasement, ο presence of large, biopsy-related hematoma, ο And pathologic fracture. ο Reconstructive options include use of allografts, endoprostheses, and occasionally rotationplasty Cont..
- 37. ο ο In the absence of chemotherapy, 80% to 90% of patients will subsequently develop distant metastases. ο Chemotherapy thus plays an important role for all patients with intermediate- and high-grade tumors ο Eilber et al. reported on 59 patients with nonmetastatic osteosarcoma ο randomized to surgery followed by observation versus adjuvant chemotherapy chemotherapy
- 38. ο ο Eilber et al. To determine the role of chemotherapy 59 patients of conventional high grade osteosarcoma 32 received MAP,and BCD .27 No chemo DFS 55% OS 80% DFS 20% OS 48% (P < .01). PEPTS OS,DFS At a median follow-up of 2 years
- 39. ο ο At a median follow-up of 2 years, there was a statistically significant improvement in both disease- free and overall survival in those who received adjuvant chemotherapy.
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- 42. ο ο Link et al. reported similar results in a group of 36 patients with nonmetastatic, high-grade osteosarcoma randomized to observation versus adjuvant chemotherapy after primary surgery. ο Disease-free survival at 2 years was 66% with chemotherapy and 17% with observation (P < .001). Cont..
- 43. ο ο Link et al 36 patients To see effect of ajuvant multiagent chemo 18 Received chemo 18 No chemo RFS at 2y 66% RFS at 2 year 17% P<0.001 At a median follow-up of 2 years PEPTS RFS
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- 46. ο ο The concept of neoadjuvant chemotherapy arose in conjunction with evolving surgical techniques striving for limb-preserving procedures and improved functional outcomes. ο This led to a randomized clinical trial by the PediatricOncology Group (POG8651). neoadjuvant chemotherapy
- 47. ο ο Advantages of neoadjuvant chemotherapy: - οΌ regression of the primary tumor, making a successful limb salvage operation easier. οΌ may decrease the spread of tumor cells at the time of surgery οΌ Effectively treating micrometastases at the earliest time possible. οΌ It avoid tumor progression, which may occur during any delay before surgery. Contβ¦
- 48. ο ο POG-8651 106 Patients 55 patients immediate surgery 45 patients neoajuvant chemo Regimen MA ,and BCD 6 excluded Limb salvage surgery 55% DFS at 5 yrs 69% Limb salvage surgery 50% DFS at 5 yrs 61% P= .8 PEPTS Limbsalv age surge DFS
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- 50. ο ο The optimal choice of chemotherapy and administration schedule remains a subject of active research The optimal choice of chemotherapy
- 51. ο ο phase 3 randomised, controlled trial. ο Consenting patients with newly diagnosed, resectable, high-grade osteosarcoma aged 40 years or younger were eligible for randomisation EURAMOS-1
- 52. ο ο EURAMOS-1 2260 patients 325 sites in 17 countries to see IE effect in poor responders 1642 Good response neoajuvant MAP 618 Poor to MAP 310 to receive MAP 308 to receive MAPIE Median follow-up was 62.1 months EFS 55% EFS 53%P = .69 PEPTS OSDFS
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- 55. ο ο Final results were unfortunately negative with neither ifosfamide and etoposide nor interferon showing improved event free survival. ο For the poor response group, at 62 months median follow-up, 3- year event-free survival was 55% for MAP and 53% MAP + IE (P = .69). ο For the good response group, at 44 months median follow-up, 3-year event-free survival was 74% for MAP and 77% MAP with interferon (P = .214 Cont..
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- 57. ο ο EOI 407 patients with operable, non-metastatic osteosarcoma PEPTS OS,PFS 16 patients excluded 199 patients Receive 18 week of AC 192 patients Receive PREOP MAV ,POSTOP,BCD,MAP OS 65% PFS 47% OS 65% PFS 47% at median of 3 years
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- 60. ο ο Chemotherapy in older patients GAETANOBACCI.ET AL 53 patients aged between 40 and 60 years Cisp +ad m 29 patients Received surg,neoa juvant chemo 24 patients Received surgery alone PEPTS EFS,OSa good histologic response received the same two drugs poor response ifosfamide and etoposide were added to cisplatin and adriamycin.
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- 63. ο ο Operative resection is the only potentially curative treatment for patients with thoracic metastases from osteogenic sarcoma. ο Following resection, adjuvant chemotherapy can improve disease-free survival and decrease the burden of metastatic pulmonary disease. ο Resection of pulmonary metastases should always be part of a combined modality approach Role of metastatectomy
- 64. ο ο Surgical margins; Negative surgical margins (defined as at least 1 cm in bone with 2β5 cm recommended) ο Therefore, limb salvage is recommended when adequate surgical margins can be achieved ο tumor responsiveness are directly associated with local recurrence: ο In patients with marginal resections and with tumor necrosis less than 90% after preoperative chemotherapy, local recurrence has been reported as high as 30% Prognostic factores
- 65. ο ο Stage at diagnose ο tumor volume ο old age, ο sex, ο and possibly p-glycoprotein expression Cont.β¦
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- 67. ο Follow up
- 68. ο ο Good documentation ο Proper work up with available set up except ALP,LDH ο EXTERNAL fixation ?? ο Proper treatment planning Case critics
- 69. ο ο Edward PΓ©rez 7th ed. ο Devita 11th ed. ο Uptodate 2018 ο NCCN 2019 ο Google References
- 70. ο ο .