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OSTEOSARCOMAA case report
Abstract
Osteosarcoma is a deadly form of musculoskeletal cancer that most commonly causes
patients to die from pulmonary metastatic disease and which has a 5-year survival rate of 15-
20%. It is regarded to be the most common highly malignant bone tumor which often affects
the adolescents and young adults. The symptoms and chances of recovery for children and
adolescents appear to be the same.
Radiography is almost always the initial imaging modality used in the investigation and with
histolopathologic studies done for the definitive diagnosis. The present management for
osteogenic sarcoma involves amputation or disarticulation collaborated with chemotherapy.
The proceeding section illustrates the etiology, pathophysiology, clinical course, diagnostic
modalities and management of a patient with OSTEOSARCOMA.
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Table of contents
Title page 1
Abstract 2
Table of contents 3
Objective of the case study 4
Significance of the case study 4
Methodology
Patient’s profile 5
History 5
Physical examination 6
Differential diagnosis 7 - 8
Course in the ward 9 - 10
Laboratory results 11 - 13
Discussion of the case 14 -18
Conclusion 19
Recommendation 19
References 20
Appendix 21 - 31
Pictures of the case
Laboratory results
Biopsy results
Others
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Objective of the case report
1. To present a case of osteosarcoma in a 17 year old patient.
2. To emphasize the role of roentgenologic study in the detection of osteogenic sarcoma.
3. To emphasize the combined role of radiographic imaging and other laboratory
modalities in the early detection of osteosarcoma.
4. To discuss the pathophysiology, clinical and features, diagnosis, management, and
prognosis of osteosarcoma.
Significance of the case report
In**** , approximately there had been 9 recorded osteosarcoma cases admitted in *****
orthopedic ward. Only a few of these patients submitted for surgical management.
Osteosarcoma is considered to be the most common malignant tumor of the bone and it is also
fatal with the patients usually failing for pulmonary metastasis. It is known to affect the
younger age group.
Radiologic imaging has a crucial role in the detection of this tumor. When detected early, its
progression and metastases could be monitored through serial x-rays. Thus, when coupled
with histopathologic study and other essential laboratory modalities, its sensitivity and
specificity to diagnose the disease is doubled.
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Methodology
Patients’ profile
A case of J.M., 17 year old male, single, Asian of the Malayan race, Roman Catholic, from
***** City was admitted for the first time on ******* in ******** due to pain and deformity of the
left leg.
History of Present Illness
3 years prior to admission, patient noted a slowly growing mass on the left leg which initially
was not associated with pain or tenderness and there was no limitation of motion noted. The
condition was tolerated and no consultation sought.
Few months prior to admission, patient started to complain of dull, constant, aching pain with
progressive increase in the size of the mass in the left leg. The pain was also aggravated
during ambulation.
1 month PTA, patient was then brought by his mother for consultation in ****** OPD where an
x-ray and biopsy was advised. Patient complied and both x-ray and biopsy results revealed
osteosarcoma. He was then advised for surgery and thus this admission.
Past History
Patient is neither a known asthmatic nor had any history of allergies to food and medications.
He claims to have no history of previous hospitalization or serious illnesses.
Personal History
J.M. was delivered in a hospital in****** . He is the youngest of 4 siblings. He was born a
healthy baby, was breastfed and personally taken cared of by his mother. His motor
development was average since he was able to walk and talk by 10 months old as claimed by
his mother. He received complete vaccination at the rural health center. During his childhood,
he was seldom afflicted with common illness like fever, cough and colds. Presently, he is still
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residing with his parents. His father worked as a plumber and his mother works as a clerk in a
nearby health center. He entered formal training in a nearby public school and it is where he
completed his high school education. Most of his closest friends are his schoolmates of which
he likes to spend time with when free from household errands. He claimed to be a non-smoker
and drinks alcoholic beverages occasionally. He also claimed to have tried prohibited drugs
with his friends out of curiosity but he claimed to have no dependency to such chemicals.
Physical examination
Examined a conscious, coherent, cooperative, ambulatory, sthenic and not in respiratory
distress with the following vital signs:
BP: 120/90 mmHg PR: 78 bpm RR: 22 cpm Temp.: 36.9 oC Wt.: 45 Kgs
Skin: warm, good turgor
HEENT: anicteric sclera, pinkish palpebral conjunctiva, no tonsillopharyngeal congestion
Neck: no masses, no tenderness, no lymphadenopathies noted
Chest/Lungs: equal chest expansion, clear breath sounds, no rales, no wheezes
CVS: distinct heart sound, normal rate and rhythm, no murmur
Abdomen: flat, normoactive bowel sounds, soft, no masses, no tenderness
GUT: (-) kidney punch sign
Extremities: presence of a firm mass approximately 12 X 14.5 cms at the proximal – middle
thirds of the left leg, (+) tenderness and warm when palpated. The right leg is unremarkable.
No limitation of motion noted. CRT < 2secs, strong pulses noted.
CNS: within normal limits
Impression: OSTEOSARCOMA, Left Tibia
Osteosarcoma is the primary consideration based on the history that the patient is still in his
adolescence. The patient is complaining of dull, constant, aching pain on his left leg. With
presenting signs of a solitary slowly growing lesion in the left leg which is also tender and
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warm when touched and is located near the left knee joint. The diagnosis is also supported by
documented plain film and biopsy results.
The plain film result of J.M. was described as a presence of cortical thickening and cloud-like
proliferation (sun-burst effect) in the external anterior surface of the proximal thirds of the left
tibia with associated soft tissue swelling of the left leg. Such radiographic finding coincides
with the textbook appearance and description of osteosarcoma.
Differential diagnosis
Chronic osteomyelitis
It is a chronic inflammatory process of the bones and its structures secondary to infection with
pyogenic organisms. It could affect all ages and has predisposition for males as it usually
results following trauma. It could present with a non-healing ulcer, flocculent mass and sinus
tract drainage, a history of fever, chronic fatigue and body malaise. It is included as one of the
differential diagnosis because its lesion usually is warm and is tender to palpate. And there is
a reduction in the use of the affected limb due to pain.
The presence and identification of the pathogenic organism could easily be documented
through hematologic studies and culture.
Radiographically, there would be evidences of soft tissue swelling which is noted as early as 3-
5 days after infection. And bony changes which are evident by 14 – 21 days and may initially
manifest as periosteal elevation followed by cortical or medullary lucencies usually by the 28 th
day. The infection extends through the vascular channels in the cortex to elevate and strip the
periosteum and the cortex. Approximately 40-50% of focal bone loss is necessary to cause
detectable lucency on plain films.
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Its exclusion in the differentials includes the fact that the patient did not have a history of
trauma or have a history of fever, chronic fatigue and body malaise. The gross appearance of
the lesion did not appear to be a flocculent mass, and did not have the usual sinus drainage
tract. The course of progression of osteosarcoma exceeds that of a chronic osteomyelitis.
The plain film appearance of osteomyelitis differs to that osteosarcoma in that the medullary
lucencies in osteomyelitis are highly evident usually appearing as a tubular lucency along the
shaft with cortical irregularity and with associated extensive demineralization of the peripheral
bone. It is further characterized by thick, irregular, cortical sclerosis with radiolucencies, an
elevated periosteum, and usually chronic draining sinuses are observed. The area of
destruction is poorly defined and has a fine, granular or slightly mottled appearance.
Chondrosarcoma
It is a malignant tumor which develops from cartilage cells. It is only about half as common as
osteogenic sarcoma, constituting 20 to 25% of all bone sarcomas and it is a tumor of
adulthood and old age with a peak incidence in the fourth to sixth decades of life. It can arise
de novo or as a malignant transformation of an enchondroma or, rarely, of the cartilaginous
cap of an osteochondroma. It has a predilection for the flat bones, especially the shoulder and
pelvic girdles. Like other bone sarcomas, high grade chondrosarcomas may spread to the
lungs. Radiographically, the lesion may have a lobular appearance with mottled or punctate
or annular calcification of the cartilaginous matrix.
It is included in our differential diagnosis because chondrosarcomas are also noted to affect
the diaphyseal portions of long bones. And it has an indolent natural history which typically
presents as pain and swelling with progressive increase in the size of the mass.
Its exclusion holds the fact that our patient is only in his adolescence as in opposition to older
age predisposition of chondrosarcoma. It differs radiographically, in that it has a lobular
appearance with mottled calcification versus that of our patient which has a sunburst
appearance. It is also noted to occur more commonly in the pelvis and less frequently seen in
the long bones. Its incidence is less common compared to osteosarcoma.
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Giant cell tumor (osteoclastoma)
It is a relatively uncommon tumor accounting for only 4-5% of primary bone tumors and 18.2%
of benign bone tumors. It is characterized by the presence of multinucleated giant cells. It is
often a solitary lesion, usually of slow rather than fast growing tumor and is seen most
frequently in young adults, peaking in those aged 20-30 years. It causes swelling with little
pain and appears in roentgenograms as an eccentric area of bone destruction. These tumors
do not have a uniform clinical course; some are quite aggressive in rapidity of growth and
destruction of bone. Most are considered benign, but many recur after curettement and a few
become frankly malignant. Metastasis to the lungs may occur.
Roentgenographic appearance shows an area of radiolucency in the epiphyseal and
metaphyseal regions of a long bone with expansion and thinning of the overlying cortex. There
are lines of relative thickening of the involved cortical bone and the reactive shell may produce
the x-ray appearance of bony septa, but these are only on the surface and do not extend
through the tumor. The lesion usually has a sharp zone of transition and is fairly well
demarcated from the normal bone, but there is no sclerotic rim.
It is included as one of the differentials due to the fact that most giant cell tumors, about 60%,
occur in the long bones including the proximal tibia, distal femur, distal radius, and proximal
humerus. Patients do often complain of pain and swelling at the affected site.
Its exclusion is made via radiography because clinically, its differentiation from osteosarcoma
is often difficult due to its comparable presentation and progression. In the plain film, this
tumor presents as an area of radiolucency in the metaphyseal and epiphyseal regions of a
long bone with expansion and thinning of the overlying cortex. Periosteal reaction is usually
minimal against that of osteogenic sarcoma.
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Course in the wards
On admission, patient came in ambulatory and vital sign were taken and were stable. Initial
laboratories were ordered and patient was then transported to the ward. In the ward, patient
was received per stretcher without IV fluid attached. Vital sign were monitored per shift and
were recorded. Patient was noted to complain of minimal dull aching pain in his left leg, but
was tolerable. The 1st hospital day was generally uneventful.
On 2nd hospital day, patient was still noted to complain of dull aching pain and was then given
Tramadol+Paracetamol (Dolcet) 325mg/37.5mg tab TID po for pain and claimed to have some
temporary relief. No other complaints noted. Laboratory results were then followed-up and
secured (refer to appendix B). Erythrocyte sedimentation rate was at 44 mm/hr (reference: 0-
10mm/hr) and the rest of the hematologic studies and urinalysis were unremarkable. The rest
of the day remained uneventful.
On the 3rd hospital day, patient was scheduled for Emergency Above Knee Amputation, Left
(AKA); and was advised to secure 1 unit of Fresh whole blood type A+. Patient was also seen
by Anesthesia and pre-operative medications were ordered and patient was then kept on NPO.
Patient was still complaining of slight breakthrough pain but claimed to be tolerable. Vital sign
still remained stable. No new complaints were noted.
4th hospital day, AKA was rescheduled due to failure to secure blood and some medications.
Instead, was rescheduled for elective surgery on the next day and patient was made to secure
an additional unit of FWB type A+ for the said contemplated surgery. Patient remained to be
stable and no new complaints noted.
5th hospital day, IVF was started with PLR 1L and regulated at 30gtts/min prior to transport.
FWB, medications and consent were secured and patient was then transported to the OR.
Surgery went uneventful lasting for almost 3 hours under spinal anesthesia and no blood
transfusion was done. The amputated extremity was given to family for biopsy. Patient was
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then transported to the recovery room where vital signs were closely monitored. Post-surgery
medications were given like Tramadol 100mg IVTT initially and then 50mg IVTT every 6 hours
thereafter; Ketorolac 30mg IVTT initially then 15mg IVTT for 3 doses; Ranitidine 50mg IVTT
initially then every 8hrs for 3 doses; and Cefuroxime 750mg IVTT every 8hrs after an initial
skin test was done. Patient displayed stable vital signs after few hours of close monitoring
thus was then transported back to the ward. In the ward, pain scoring was recorded every 2
hours, patient was already complaining of pain in the left groin and thigh. Patient was noted to
have difficulty of sleeping due to post-operative pain.
6th – 7th hospital day, patients recovery was noted to be at par. Pain was gradually
deteriorating to tolerable state. Daily wound care was done. Vital signs and pain score
monitored regularly. Intravenous fluid and medications were continued.
8th hospital day, family was noted to refuse sending the amputated limb for biopsy for financial
reasons. Post-operative recovery was still at par. No signs of fever or infection noted. Pain
was gradually deteriorating.
9th hospital day, post-op recovery was still at par. Pain was tolerable and vital signs remained
stable. No signs of fever or infection noted. Daily wound care and intravenous medications
were still continued.
10th hospital day, patient was seen by IM-oncology section and was advised for chemotherapy
and also advised to take Multivitamins+Iron 1 tab po daily. No new complaints noted.
11th hospital day, intravenous fluid and parenteral medications were discontinued. Oral
medications were started with Cefuroxime 500mg cap bid po and Mefenamic acid 500mg cap
TID po.
12th hospital day, patient was again visited by IM-oncology section and was advised to follow-
up as OPD on ******* in IM office for scheduling of chemotherapy.
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13th hospital day, patient was allowed to go home with take home meds of Cefuroxime 500mg
cap BID po for 10 days more and Mefenamic acid 500mg cap TID po for 7 days more. Patient
was also schedule to visit the Rehab department for his physical therapy management on
******** and to follow-up in orthopedics in ****** OPD on the same day. Patient was
discharged improving.
Laboratory results
Complete blood count
Hematocrit = 0.44/L
White blood cell = 10. 25 x 109/L
Segmenters = 0.66
Monocytes = 0.01
Lymphocytes = 0.26
Platelets 345x109/L
Blood type A+
Urinalysis
Color = Yellow Red blood Cells = 0-1/hpf
Transparency = Cloudy Pus Cells = 0-1/hpf
Reaction = pH 6.0 Amorphous Urates = Abundant
Specific Gravity = 1.030 Bacteria = Rare
Sugar = Negative
Protein = Negative
CT-BT
Clotting Time = 3 mins x 5 secs
Bleeding Time = 1 min x 2 secs
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Partial Thromboplastin Time (PTT/APTT)
Patient 39.2 secs
Control 35.5 secs
ESR
Erythrocyte Sedimentation Rate = 45 mm/hr
Prothrombin Time
Patient = 12 secs
Activity = 91.3%
INR = 1.01
Control = 11.3 secs
Control Activity = 102.8%
Chest X-ray report
The trachea and mediastinum are in the midline. The heart is normal in size and shape. The
lung fields on both sides are also normal. The diaphragms are smooth. The costophrenic
angles are sharp. The bony thorax shows no abnormality.
Conclusion: Negative Chest
Chest X-ray report
Both lung fields are clear. The heart is normal in size and shape. The trachea is at the
midline. The diaphragms are depressed. The osseous thoracic cage showed no significant
bony abnormality.
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Conclusion: Hyperaeration of both lungs. This raises the question of lower airway obstruction
(Bronchial Asthma).
X-ray of the Left Leg APL
There is cortical thickening and cloudlike proliferation in the external anterior surface of the
proximal 3rd to the middle 3rd of the left tibia with soft tissue swelling. The epiphyses are not
fused yet.
Conclusion: The above findings is suggestive of periosteal osteosarcoma, suggest biopsy.
Fine Needle Aspiration Biopsy, Left Anterior Leg
Smears are moderately cellular consisting of sheets, clusters and individually scattered of
highly atypical spindle-shaped cells. These cells have round to ovoid, pleomorphic, and
hyperchromatic nuclei with coarse chromatin pattern surrounded by a scanty cytoplasm. No
organoid pattern is seen. The background is bloody.
Diagnosis: Cellular findings highly suggestive of sarcoma
Surgical Pathology report
Gross description: The specimen consists of a few fragments of firm, light brown tissue
admixed with blood clots measuring 1 cm in aggregate. These are entirely processed.
Microscopic: Section shows fragments of a malignant neoplasm composed of tumor cells with
large, pleomorphic and hyperchromatic nuclei, some vesicular with conspicuous nucleoli and
some with intranuclear inclusions. Several mitotic figures are seen. These cells are
surrounded by small irregular trabeculae of eosonophilic osteoid.
Diagnosis: Tibia, left, middle third, shaft: OSTEOSARCOMA
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Discussion of the case
Background
It is the most common malignant bone tumor (Vander Griend, 1996). And it is thought to arise
from primitive mesenchymal bone-forming cells and later becoming a malignant osteoid. It is a
deadly form of musculoskeletal cancer that most commonly causes patients to die from
pulmonary metastatic disease.
History
Osteosarcoma is an ancient disease that is still incompletely understood. The term sarcoma
was introduced by the English surgeon John Abernathy in 1804 and was derived from Greek
roots meaning fleshy excrescence (Peltier, 1993). In 1805, the French surgeon Alexis Boyer
(personal surgeon to Napoleon) first used the term osteosarcoma and he realized that it is a
distinct entity from other bone lesions such as osteochondromas (exostoses). Its gross
appearance was described 1847 by Baron Guillaume Dupuytren as a whitish or reddish mass,
lardaceous and firm at an early stage of the disease; but presenting at a later period, points of
softening, cerebriform matter, extravasating blood, and white or straw colored fluid of a viscid
consistence in its interior.
Incidence
The incidence of osteosarcoma is slightly higher in males than in females with males (5.2 per
million per year) and females (4.5 per million per year). It is very rare in young children (0.5
cases per million per year in children <5 y), incidence increases steadily with age, increasing
more dramatically in adolescence, corresponding with the growth spurt.
Etiology
Rapid bone growth appears to predispose persons to osteosarcoma, as suggested by the
increased incidence during the adolescent growth spurt, and osteosarcoma’s typical location in
the metaphyseal area adjacent to the growth plate (physis) of long bones.
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There are some evidences of genetic predisposition for osteosarcoma in patients with bone
dysplasia (Paget disease, fibrous dysplasia, enchondromatosis, and hereditary multiple
exostoses and retinoblastoma). It is thought that the combination of constitutional mutation of
the RB gene and radiation therapy might develop chances for osteogenic mutation. The only
known environmental risk factor is exposure to radiation. But in most cases of osteogenic
sarcoma no definite cause can be determined.
Pathophysiology
Osteosarcoma is a malignant mesenchymal sarcoma characterized by the direct formation of
bone or osteoid by tumor cells. Osteosarcoma is subclassified depending on the histologic
characteristics of the cells. When the majority of the cells produce osteoid, the tumor is called
osteoblastic. Where production of chondroid matrix is predominant, the tumor is classified as a
chondroblastic osteosarcoma. When spindle cells are in the majority and little matrix is formed,
the term fibroblastic osteosarcoma is used.
Anatomical PredispositionIt usually arise as solitary lesions within the fastest growing areas of the long bones, with the
top three sites includes the femur (42%, 75% of which are distal femur), tibia (19%, 80% of
which are proximal tibia), humerus (10%, 90% of which are proximal humerus), and other
significant locations are the skull and jaw (8%) and pelvis (8%), but virtually any bone can be
affected. Not all osteosarcomas arise in a solitary fashion, as multiple sites may become
apparent within a period of about 6 months (synchronous osteosarcoma), or multiple sites may
be noted over a period longer than 6 months (metachronous osteosarcoma). Such multifocal
osteosarcoma is decidedly rare, but when it occurs, it tends to be in patients younger than 10
years
Clinical Presentation
Pain, as a rule the first symptom, is of dull, constant, aching character and often interferes with
sleep. The usual physical examination findings include a palpable mass which may or may not
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be present. The mass may be tender and warm, though these signs are indistinguishable from
osteomyelitis. In the case of lower limb lesions, the discomfort may result in a slight limp.
Pathologic fracture is uncommon in osteogenic sarcoma. In rapidly growing tumors, distention
of the superficial veins and elevation of the skin temperature over the lesion are common.
Pulsations or a bruit may sometimes be detectable. The range of motion might be decreased if
a joint is involved. Involvement of local or regional lymph nodes is unusual. Auscultation is
usually uninformative unless disease is extensive. In more than half of patients the serum
alkaline phosphatase level is elevated, reflecting the osteoblastic activity of the tumor cells.
Laboratory
Important laboratory studies include the following:
LDH (it is helps to determine the present state of cell turnover)
Alkaline phosphatase (is of prognostic significance because an elevated alkaline
phosphatase at diagnosis is more likely to have pulmonary metastases)
CBC count with Platelet count (hematology may also help to determine if concomitant
anemia is existing)
Liver function tests: Aspartate aminotransferase, alanine aminotransferase, bilirubin,
and albumin (it helps to assess liver status and possible involvement)
Electrolytes: Sodium, potassium, chloride, bicarbonate, calcium, magnesium,
phosphorus
Renal function tests: BUN, creatinine
Urinalysis
Imaging Studies
X-rayRoentgenographic picture shows areas of both bone destruction and of new bone
formation. The degree of each is highly variable, some tumors being very radiopaque
and others showing extensive demineralization with areas of cortical destruction where
tumor has broken through and elevated overlying periosteum or cortical extension is
seen. Beneath this expanded periosteal sleeve, small spicules of bone radiating at right
angles to the shaft (sunburst effect) are frequently present. At proximal and distal
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extremes of this elevated periosteum a small triangle of reactive bone, Codman’s
triangle, may be found.
It is advisable to obtain plain films of the suspected lesions in 2 views. It is important to
note that no single feature on radiograph is diagnostic. Taking chest film is of value in
order to determine if the pulmonary system is already involved.
CT scanA CT-scan of the primary tumor is best for defining bone destruction and the pattern of
the calcification. It is critical for surgical planning
MRIIt is the best method to assess the extent of intramedullary disease as well as
associated soft tissue masses and skip lesions. It is also the single most important
study for accurate surgical staging of the lesion using the Enneking staging system.
Enneking staging system (1983)
The purpose of staging tumors is to stratify risk groups. It is also referred to as the staging
system of the Musculoskeletal Tumor Society and this system applies to al`l musculoskeletal
tumors (both bone and soft tissue). The key components to the staging system are the
histologic grade of the tumor (low grade versus high grade), anatomic location of the tumor
(intracompartmental versus extracompartmental), and the absence or presence of metastatic
disease.
The staging system is typically depicted as follows:
Low-grade tumor, intracompartmental - I-A
Low-grade tumor, extracompartmental - I-B
High-grade tumor, intracompartmental - II-A
High-grade tumor, extracompartmental - II-B
Any tumor with evidence of metastases– III
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Substage A - Intracompartmental lesion (intramedullary lesion for bone
tumors)
Substage B - Extracompartmental lesion (extramedullary spread for bone
tumors)
Radionuclide bone scansIt uses technetium Tc 99-methylene diphosphonate and it is important to evaluate for
the presence of metastatic or multifocal disease with a bone scan.
Angiography It is not helpful for diagnosis, but it is the most sensitive test for assessing the response
to preoperative chemotherapy. Most osteosarcomas are high grade.
Histopathology
The tumor cells have a frankly sarcomatous appearance, with large, bizarre, and
hyperchromatic nuclei and frequent mitotic figures. The cells contain high levels of
alkaline phosphatase. The hallmark of osteogenic sarcoma is the osteoid matrix
produced by the tumor cells. The tumor interdigitates with trabeculae of normal
metaphyseal bone.
Treatment
The orthopedic surgeon is of paramount importance in the care of patients with osteosarcoma.
Since osteosarcomas are not particularly responsive to radiotherapy, surgery is the only option
for definitive tumor removal (local control). In addition, an oncologic type of total joint
prosthesis or complex bone reconstruction may be required following surgical resection.
Therefore, close involvement of the orthopedic surgeon with the medical oncologist at the time
of diagnosis, as well as during and after chemotherapy, is critical.
The primary aim of definitive resection is patient survival. As such the margins on all sides of
the tumor must contain normal tissue (wide margin). The thickness of the margin is important
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only for the marrow, where an adequate margin is thought to be 5-7 cm from the edge of
abnormality depicted on MRI or bone scan. But amputation may be the treatment of choice in
some circumstances.
When amputation is decided, a well planned rehabilitative program should be designed in
partnership with the physiatrist and physical therapist for the patient’s post-amputation
recovery.
The most important prognostic factor for long-term survival is response to chemotherapy.
Preoperative (neoadjuvant) chemotherapy followed by limb-sparing surgery (which can be
accomplished in > 80% of patients) followed by postoperative (postadjuvant) chemotherapy is
standard management. The use of neoadjuvant chemotherapy has been found to facilitate
subsequent surgical removal by causing tumor shrinkage and has also provided oncologists
with an important risk parameter. Patients who have a good histopathological response to
neoadjuvant chemotherapy (>95% tumor cell kill or necrosis) have a better prognosis than
those whose tumors do not respond as favorably. The effective drugs are doxorubicin,
ifosfamide, cisplatin, and high-dose methotrexate with leucoverin rescue.
Prognosis
The present understanding of outcome and prognosis for osteosarcoma is driven by certain
serum markers, clinical staging, and histologic response to chemotherapeutic agents. The
overall 5-year survival rate for patients diagnosed between 1974 and 1994 was 63% (59% for
males, 70% for females). Patients with elevated alkaline phosphatase at diagnosis are more
likely to have pulmonary metastases. In patients without metastases, those with an elevated
LDH are less likely to do well than are those with a normal LDH. Long term survival rates in
extremity osteosarcoma range from 60 to 80%. Osteosarcoma is radioresistant; radiation
therapy has no role in the routine management.
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Conclusion
Osteosarcoma is a serious and fatal disease of the bones in which patients would die of
pulmonary cause. It usually affects the younger age group, peaking during the adolescent and
in the young adult. Clinically, it usually manifests as a slowly growing solitary mass in the long
bones and is frequently seen around the joint area. It is also associated with dull, aching pain
around the lesion. Its diagnosis is based mainly on clinical findings. Radiologic study of
osteosarcoma plays an essential role in the surgeon’s diagnosis. It is a diagnostic modality
that is easily available; it is non-invasiveness, and is highly sensitive in illustrating the disease.
The definitive diagnosis is eventually made through biopsy. Once diagnosis is made, it is
usually managed surgically with amputation of the affected limb and supported with
chemotherapy.
Recommendation
The occurrence of osteosarcoma in our medical center is common with early detection and
management being crucial in improving the outcome patient’s recovery. The author would like
to make the following recommendations:
To educate patients who are diagnosed with osteosarcoma about the disease, signs and
symptoms, different kinds of treatment and its outcome.
To create an organized multi-disciplinary body geared especially in the treatment of
osteosarcoma. This involves the team approach of the departments of Orthopedic, IM-
Oncology, Radiology, Pathology, Rehabilitation-Medicine and Psychiatry, especially if it is a
pediatric patient with a contemplated amputation being perceived.
I would also recommend that a formal inquiry of the present statistic on the occurrence of
osteosarcoma in our hospital be conducted. This includes the management and outcome, and
recurrence after chemotherapy if present.
The participation of psychiatry department be encourage in the present management of
osteosarcoma patients as they play a crucial role in its pre-and post- operative management.
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References1. Paul and Juhl’s Essentials of Radiologic Imaging 7th Ed., 4: 162-168. 1998
2. Eisenberg Clinical Imaging, An Atlas of Differential Diagnosis 4 th Ed., 859f, 784-785.
2003
3. Resnick Bone and Joint Imaging 2nd Ed., 14: 1001-1007. 1989
4. Brashear and Raney Handbook of Orthopedic Surgery 10th Ed., 7: 250-255. 1986
5. eMedicine Online
6. American Cancer Society
7. Radiologic Society of North America 1995
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