Post on 02-Jun-2018
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OSTEOSARCOMA
Gopal Singh
Lecturer
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Oncology defined
Branch of medicine that deals with the
study, detection, treatment and
management of cancer and neoplasia
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Root words
Neo- new
Plasia- growth
Plasm- substance
Trophy- size
+Oma- tumor
Statis- location
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Characteristics of Neoplasia
Uncontrolled growth of Abnormal cells
1. Benign
2. Malignant
3. Borderline
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Characteristics of Neoplasia
Benign
Well-differentiated
Slow growth
Encapsulated
Non-invasive
Does NOT metastasize
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Characteristics of Neoplasia
Malignant
Undifferentiated
Erratic and Uncontrolled Growth
Expansive and Invasive
Secretes abnormal proteins
Metastasizes
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Age(probably the most important clinical clue).
Age groupMost common b enign
les ions
Most common m alignant
tumors
0 - 10simple bone cyst
eosinophilic granuloma
Ewing's sarcoma
leukemic involvementmetastatic neuroblastoma
10 - 20
non-ossifying fibroma
fibrous dysplasia
simple bone cyst
aneurysmal bone cyst
osteochondroma (exostosis)osteoid osteoma
osteoblastoma
chondroblastoma
chondromyxoid fibroma
osteosarcoma,
Ewing's sarcoma,adamantinoma
20 - 40enchondroma
giant cell tumorchondrosarcoma
40 & above osteoma
metastatic tumorsmyeloma
leukemic involvement
chondrosarcoma
osteosarcoma (Paget's
associated)
MFH
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Defination
Osteosarcoma is the name given to aheterogeneous group of malignant spindle celltumors that have as their common feature the
production of immature bone, also known asOSTEOID.
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Epidemiology
It is the second most common primary
malignancy of bone
The incidence is approximately 1-3 per 1
million per year.
Male>female
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Epidemiology
Most common sites are the
Distal femur
Proximal tibia Proximal humerus
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Risk Factors/Etiology
The exact cause of osteosarcoma is
unknown
Rapid bone growth
Environmental factors (exposure to radiation
)
Known causative agents are divided into
Chemicals
Viruses
radiation
miscellaneous
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Classification
Osteosarcomas are categorized asprimary or secondary.
Primary Osteosarcomas are
Conventional osteosarcoma, Low-grade intramedullary osteosarcoma,
Parosteal osteosarcoma,
Periosteal osteosarcoma,
High-grade surface osteosarcoma, Telangiectatic osteosarcoma, and
Small cell osteosarcoma
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Classification .
Secondary osteosarcomas
Osteosarcomas occurring at the site of
another disease process The most common are
Paget disease
Previous radiation treatment
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Classification .
Other associated conditions are Fibrous dysplasia,
Bone infarcts,
Osteochondromas, Chronic osteomyelitis,
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Clinical feature
Pain
The pain may be progressive for manymonths, and initially be confused with
more common sources such as musclesoreness, overuse injury or "growingpains."
Night pain is an important clue to the truediagnosis (25%)
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Clinical feature
Swelling
Palpable mass is noted in up to 1/3 ofpatients at the first visit
LimpIn smaller children, a limp may be the onlysymptom
Restriction of movement of the adjacent
joint Pathological Fracture
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Lab: Investigation
Full blood count, ESR, CRP.
LDHALP (elevated levels at diagnosis signify
increased risk of pulmonary metastasis) Platelet count
Electrolyte levels Liver function tests Renal function tests
Urinalysis
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Radiology: Investigation
CT scanning
CT scanning of the chest is more sensitive than is plainfilm radiography for assessing pulmonary metastases.
MRIMRI of the primary lesion is the best method to assessthe extent of intramedullary disease as well asassociated soft-tissue masses and skip lesions.
Bone ScanA bone scan should be obtained to look for skeletal
metastases or multi focal disease.
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Others Investigation
Thallium scanMonitor effects of chemotherapyDetect local recurrence of tumor
AngiographyDetect vascular displacement anddetermine relationship of vessels to the
tumorIdentify vascular anomalies
Estimate effects of chemotherapy.
Once all the initial imaging & lab exam hasbeen done biopsy is performed to con formthe diagnosis.
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Biopsy
Biopsy
Principles of Biopsy:
A biopsy should be planned as carefully
as the definitive procedure.
Biopsy should be done only after complete
clinical, laboratory, and radiographicexaminations.
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Biopsy
Transverse incisions should be avoided.
The deep incision should go through asingle muscle compartment.
Biopsy should be taken from the peripheryof a lesion as it usually contains the most
viable tissue.
The wound should be closed tightly inlayers.
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Types of biopsy
Fine needle aspiration
Core needle biopsy
Open incisional biopsy
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Staging
The staging system devised and
introduced by Enneking in 1980 is applies
to all musculoskeletal tumors.
Staging system are the
Histologic grade of the tumor
(low grade vs high grade)
Anatomic location of the tumor intracompartmental vs extracompartmental
Absence or presence of metastatic disease
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Staging ..
Stage I: Low grade tumors
I-A intra compartmental
I-B extra compartmental
Stage II: High grade tumors
II-A intra compartmental
II-B extra compartmental
Stage III: Any tumors with evidence ofmetastasis
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Staging
American Joint Committee on Cancer Systemfor Staging Bone Sarcomas
Based on grade & size of tumor and presence
of metastasisStage Grade Size MetastasesI-A Low 8 cm NoneI-B Low >8 cm None
II-A High 8 cm NoneII-B High >8 cm NoneIII Any Any Skip metastasisIV-A Any Any Pulmonary metastasesIV-B Any Any Nonpulmonary metastases
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Treatment
1. Radiological staging
2. Biopsy to confirm diagnosis
3. Preoperative chemotherapy
4. Repeat radiological staging(access chemo response, finalize surgical tx plan)
5. Surgical resection with wide margin
6. Reconstruction using one of many
techniques
7. Post op chemo based on preop response
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Treatment .
The drugs used most often to treatosteosarcoma are: Methotrexate with leucovorin (folinic acid)
Doxorubicin (Adriamycin) Cisplatin or carboplatin
Etoposide
Ifosfamide
CyclophosphamideActinomycin D (dactinomycin)
Bleomycin
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Treatment ..
Some common combinations of drugsinclude:
Cisplatin and Adriamycin (CA)
Vincristine, Methotrexate, Leucovorin &
Adriamycin
High-dose methotrexate, Adriamycin, and
cisplatin (sometimes with ifosfamide) Dactinomycin, bleomycin and cyclophosphamide
Ifosfamide and Etoposide
frequency....... Repeat cycle every 21 days
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Side effect
General side effects: Nausea and vomiting, Loss of appetite, Hair loss,
Mouth sores.
Chemotherapy can damage the blood-producing cells resulting in:
Increased chance of infection ( W B C) Bleeding or bruising (Platelets) Fatigue or shortness of breath (RBCs)
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Side effect..
Side effects of specific drugs. Ifosfamide and cyclophosphamide : hemorrhagic cystitis.
Cisplatin: neuropathy, nephropathy, ototoxicity.
High-dose methotrexate: leukoencephalopathy and liver or kidney
damage. Doxorubicin (Adriamycin): can cause heart damage over time.
Long-term side effects:
Infertility
Heart damage
Developing a second cancer(
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Surgery
The main goal of surgery is to safely andcompletely remove the tumor.
Historically, most patients had an amputation.
Wide resection & prosthetic knee replacement Transfemoral amputation is common
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Complication of surgery
Hematoma
Infection
Wound necrosis
Contracture Pain
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Ewings Sarcoma
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Introduction
Identified in 1921 by James Ewing
Differed from osteogenic sarcoma
Different location
Poor survival: 5-10% at 5 years
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Epidemiology
Incidence is 0.6 per million
Males > Females
Rare in blacks and Asians
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Clinical Features
Pain most commonly (90%)
Swelling (70%)
Fever (20%)
Pathological fracture
Weight loss
Malaise
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Clinical Features ..
Local warmth, inflammation
Pleural effusions
Neurological signs if spinal involvement
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Investigation
ESR
LDH
Anemia
Leukocytosis
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Investigation: Radiology
Site
Size
Effect on bone
Response of Bone
Matrix
Cortex
Soft tissue
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Staging
Local and distal staging
Bone marrow aspirate
Pre-chemotherapy investigations
Biopsy
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Staging
Location
Tumor Size
Metastases at diagnosis
Response to chemotherapy
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Treatment
Multidisciplinary approach
Neoadjuvant chemotherapy
Surgery
Radiation
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Nursing Intervention
Promote Nutrition
Serve food in ways to make it appealing
Provide small frequent meals
Avoids giving fluids while eating
Oral hygiene PRIOR to mealtime
Vitamin supplements
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Nursing Intervention..
Relieve Pain
Mild pain- NSAIDS
Moderate pain- Weak opiods
Severe pain- Morphine
Administer analgesics round the clock with
additional dose for breakthrough pain
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Nursing Intervention..
Decrease Fatigue
Plan daily activities to allow alternating rest
periods
Light exercise is encouraged
Small frequent meals
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Nursing Intervention..
Improve body image
Therapeutic communication is essential
Encourage independence in self-care and
decision making
Offer cosmetic material like make-up and wigs
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Nursing Intervention..
Assist in the grieving process
Some cancers are curable
Grieving can be due to loss of health, income,
sexuality, and body image
Answer and clarify information about cancer
and treatment options
Identify resource people Refer to support groups
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Nursing Intervention..
Manage Complication: Infection
Fever is the most important sign (38.3)
Administer prescribed antibiotics X
2weeks Maintain aseptic technique
Avoid exposure to crowds
Avoid giving fresh fruits and veggie Handwashing
Avoid frequent invasive procedures
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Nursing Intervention..
Manage complication: septic shock
Monitor VS, BP, temp
Administer IV antibiotics
Administer supplemental O2
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Nursing Intervention..
Manage Complication: Bleeding
Thrombocytopenia (