Bone Tumor Gopal

8/11/2019 Bone Tumor Gopal

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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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Benign

Well-differentiated

Slow growth

Encapsulated

Non-invasive

Does NOT metastasize


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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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Decrease Fatigue

Plan daily activities to allow alternating rest

periods

Light exercise is encouraged

Small frequent meals


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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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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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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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Manage complication: septic shock

Monitor VS, BP, temp

Administer IV antibiotics

Administer supplemental O2


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Manage Complication: Bleeding

Thrombocytopenia (

Bone Tumor Gopal

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