Osteosarcoma

1. BISMILALLAH ALREHMANBISMILALLAH ALREHMAN
ALAHEEMALAHEEM

2. MR SARDAR SAJID MEHMOOD KHANMR SARDAR SAJID MEHMOOD KHAN
MBBS, MRCS (Ireland), FCPS (Ortho),FEBOTMBBS, MRCS (Ireland), FCPS (Ortho),FEBOT
Whipps Cross University HospitalWhipps Cross University Hospital
LondonLondon

3. OSTEOSARCOMAOSTEOSARCOMA
 Osteosarcoma is primary malignant boneOsteosarcoma is primary malignant bone
forming tumorforming tumor
 Common in young children and adolescents atCommon in young children and adolescents at
growing ends of bonesgrowing ends of bones

4. OSTEOSARCOMAOSTEOSARCOMA

7. HIST0RYHIST0RY
 An ancient disease present in Greek, EgyptianAn ancient disease present in Greek, Egyptian
& Indian literature.& Indian literature.
 SARCOMA derived from Greek roots, meansSARCOMA derived from Greek roots, means
fleshy excrescence, used first time by Englishfleshy excrescence, used first time by English
Surgeon, JOHN ABERNATHY in 1804.Surgeon, JOHN ABERNATHY in 1804.
 OSTEOSARCOMA, first time used by FrenchOSTEOSARCOMA, first time used by French
Surgeon, Alexis Boyer in 1805Surgeon, Alexis Boyer in 1805
(PERSONEL SURGEON TO NAPOLEON)(PERSONEL SURGEON TO NAPOLEON)

8. HISTORYHISTORY
 1847,BORON GUILLAUME DUPUYTREN1847,BORON GUILLAUME DUPUYTREN
demonstrated gross pathologic appearance asdemonstrated gross pathologic appearance as
 Osteosarcoma is a true cancerous degenerationOsteosarcoma is a true cancerous degeneration
of bone, manifest itself in the form of white orof bone, manifest itself in the form of white or
reddish mass, lardaceous and firm at an earlyreddish mass, lardaceous and firm at an early
stage of disease but presenting at latter stagestage of disease but presenting at latter stage
points of softening, cerebriform matter,points of softening, cerebriform matter,
extravasating blood, and white or strawextravasating blood, and white or straw
colored fluid of viscid consistence in itscolored fluid of viscid consistence in its
interior.interior.

9. HISTORYHISTORY
 1900,VITTORIO PUTTI,SCAGLIETTI &1900,VITTORIO PUTTI,SCAGLIETTI &
COMPANACCI from ITLAY shaped treatment forCOMPANACCI from ITLAY shaped treatment for
Bone Tumor.Bone Tumor.
 1921,ERNEST AMROY CODMAN &JAMES1921,ERNEST AMROY CODMAN &JAMES
EWING created registry for Bone Sarcoma.EWING created registry for Bone Sarcoma.
 1950,HENRY L.JAFFE,LOUIS LICTENSTEIN1950,HENRY L.JAFFE,LOUIS LICTENSTEIN
established all key histological criteria used toestablished all key histological criteria used to
diagnose most of Bone Tumors.diagnose most of Bone Tumors.

10. HIST0RYHIST0RY
 1970,NORMAN JAFFE, introduced1970,NORMAN JAFFE, introduced
Chemotherapeutic agents such asChemotherapeutic agents such as
METHOTREXATE & ADRIAMYCIN,METHOTREXATE & ADRIAMYCIN,
dramatically improved the treatment ofdramatically improved the treatment of
Osteosarcoma through their ability to treatOsteosarcoma through their ability to treat
Micro metastasis.Micro metastasis.
 1976,ROSEN introduced Custom made1976,ROSEN introduced Custom made
Prosthesis.Prosthesis.

11. HISTORYHISTORY
 1980,ENNEKING1980,ENNEKING
Surgical Staging of MusculoskeletalSurgical Staging of Musculoskeletal
Sarcomas.Sarcomas.

13. INCIDENCEINCIDENCE
 Sixth leading cancer under age of 15Sixth leading cancer under age of 15
 In USA 400 cases per Year.In USA 400 cases per Year.
(4.8 per Million <20 Y ),(4.8 per Million <20 Y ),
More common in black AmericansMore common in black Americans
 Male 5.2 per Million per year,Male 5.2 per Million per year,
Female 4.2 per Million per yearFemale 4.2 per Million per year
 Rare below 5 year(0.5 per Million per year)Rare below 5 year(0.5 per Million per year)
 300 die in each year300 die in each year
 22NDND
peak in incidence in Elderly, associated with Pagetpeak in incidence in Elderly, associated with Paget
disease, Bone infarct, or Post radiation.disease, Bone infarct, or Post radiation.

14. Common sites

15. LOCATIONLOCATION
 FEMURFEMUR 42%(75% DISTAL)42%(75% DISTAL)
 TIBIATIBIA 19%(80% PROXIMAL)19%(80% PROXIMAL)
 HUMERUSHUMERUS 10%(90% PROXIMAL)10%(90% PROXIMAL)
 SKULL &SKULL & JAWJAW 8%8%
 PELVISPELVIS 8%8%

16. DISTAL FEMURDISTAL FEMUR
Most common site

17. PROXIMAL TIBIAPROXIMAL TIBIA

18. PROXIMAL HUMERUSPROXIMAL HUMERUS

19. DISTAL RADIUSDISTAL RADIUS

20. ILEUMILEUM
 Metastasize toMetastasize to
 sacrum,sacrum,
 contra lateralcontra lateral
 ileum,ileum,
 hiphip


21. LUMBER VERTEBRALUMBER VERTEBRA

22. MANDIBLEMANDIBLE

23. RIBRIB

24. SCAPULASCAPULA

25. SKULLSKULL

26. ETIOLOGYETIOLOGY
 Exact cause is unknownExact cause is unknown
 Risk factorsRisk factors
1;Rapid Bone Growth1;Rapid Bone Growth
2;2; RadiationRadiation
3;Genetic predisposition3;Genetic predisposition

27. ETIOLOGYETIOLOGY
 Bone Dysplasias, including Paget Disease,
Fibrous Dysplasias, Enchondromatosis,
Hereditary Multiple Exostosis &
Retinoblastoma (Germ Line)
*Mutations in Tumor Suppressor Genes,P53
& Rb have major role in Osteosarcoma
development

28. PATHOLOGYPATHOLOGY

30. PATHOLOGYPATHOLOGY
 Localized at Metaphyseal ends of Long BonesLocalized at Metaphyseal ends of Long Bones
 Solid, Hard, Irregular due to Tumor Spicules ofSolid, Hard, Irregular due to Tumor Spicules of
Calcified Bone, Surrounding Tissue infiltratedCalcified Bone, Surrounding Tissue infiltrated

31. PATHOLOGYPATHOLOGY
 Microscopically, Tumor Cells are Pleomorphic,someMicroscopically, Tumor Cells are Pleomorphic,some
are Giant with numerous Mitosis, producingare Giant with numerous Mitosis, producing
Amorphous, Eosinophilic Osteoid with or withoutAmorphous, Eosinophilic Osteoid with or without
central Calcification.central Calcification.

34. HISTOLOGICAL VARIANTHISTOLOGICAL VARIANT
 OsteoblasticOsteoblastic
 ChondroblasticChondroblastic
 FibroblasticFibroblastic
 Ana plasticAna plastic
 TelangiectaticTelangiectatic

35. CLINICAL VARIANTSCLINICAL VARIANTS
 PeriostealPeriosteal
 ParostealParosteal
 MultifocalMultifocal
SynchronousSynchronous
MetachronousMetachronous
 TelangiectaticTelangiectatic
 SecondarySecondary
RadiationRadiation
Paget DiseasePaget Disease
Bone DysplasiasBone Dysplasias
 ClassicalClassical

36.  MetaphysealMetaphyseal
 OsteoscleroticOsteosclerotic
 SunburstSunburst
 Codman TriangleCodman Triangle

38. PAROSTEAL OSTEOSARCOMAPAROSTEAL OSTEOSARCOMA

40. PERIOSTEAL OSTEOSARCOMAPERIOSTEAL OSTEOSARCOMA
 DiaphysealDiaphyseal
 Cortical encirclingCortical encircling
 High gradeHigh grade

41. TELANGIECTATICTELANGIECTATIC
OSTEOSARCOMAOSTEOSARCOMA
 RadiolucentRadiolucent
 Little Periosteal reactionLittle Periosteal reaction


42. RADIOLOGICAL DIFFERENTIALRADIOLOGICAL DIFFERENTIAL
DIAGNOSISDIAGNOSIS
 Ewing SarcomaEwing Sarcoma
 OsteomyelitisOsteomyelitis
 OsteoblastomaOsteoblastoma
 Giant cell tumorGiant cell tumor
 Fibrous DysplasiaFibrous Dysplasia

43. EWING SARCOMAEWING SARCOMA
DiaphysealDiaphyseal
Onion peelOnion peel
Soft Tissue MassSoft Tissue Mass

44. OSTEOMYELITISOSTEOMYELITIS

45. BONE INFARCTBONE INFARCT

46. CLINICAL PRESENTATIONCLINICAL PRESENTATION
 Bone PainBone Pain
Most Common Symptom present atMost Common Symptom present at
night or afternight or after
exerciseexercise
 SwellingSwelling
 Decreased Joint MotionDecreased Joint Motion
 Pathological FracturePathological Fracture
 Respiratory symptomsRespiratory symptoms
Due to MetastasisDue to Metastasis

47. CLINICAL SIGNSCLINICAL SIGNS
 MassMass
Palpable mass may or may not present,Palpable mass may or may not present,
may be warm & tender, firm to hard, increasedmay be warm & tender, firm to hard, increased
skin vascularity over mass.skin vascularity over mass.
 Decreased Joint MobilityDecreased Joint Mobility
 LymphadenopathyLymphadenopathy
 Respiratory FindingsRespiratory Findings

50. DIAGNOSTIC TOOLSDIAGNOSTIC TOOLS
 Plain X-RayPlain X-Ray
 Total Body ScanTotal Body Scan
 MRI of Primary TumorMRI of Primary Tumor
 CT Scan LungCT Scan Lung
 BiopsyBiopsy
 Laboratory StudiesLaboratory Studies

55. LUNG METASTASISLUNG METASTASIS
CT SCAN

56. LABORATORY WORKLABORATORY WORK
 CBC CountCBC Count
 LDHLDH
 Alkaline PhosphateAlkaline Phosphate

57. INESTIGATIONSINESTIGATIONS
Monitoring ChemotherapyMonitoring Chemotherapy
 LFTs,RFTs,Electrolytes,UrinalysisLFTs,RFTs,Electrolytes,Urinalysis
 Echocardiogram(Adriamycin)Echocardiogram(Adriamycin)
 Audiogram(Cisplatin)Audiogram(Cisplatin)

58. BIOPSYBIOPSY
 Needle BiopsyNeedle Biopsy
craig needlecraig needle
 Open BiopsyOpen Biopsy

59. STAGINGSTAGING

60. ENNEKING STAGINGENNEKING STAGING
 Stage-1Stage-1
Low GradeLow Grade
A-Intra CompartmentalA-Intra Compartmental
B-Extra CompartmentalB-Extra Compartmental
 Stage-11Stage-11
High GradeHigh Grade
A-Intra CompartmentalA-Intra Compartmental
B-Extra CompartmentalB-Extra Compartmental
 Sstage-111Sstage-111
MetastasisMetastasis

61. TREATMENTTREATMENT
 ChemotherapyChemotherapy
NeoadjuvantNeoadjuvant
AdjuvantAdjuvant
 SurgerySurgery
AmputationAmputation
Wide Resection & ReconstructionWide Resection & Reconstruction
Resection of Pulmonary MetastasisResection of Pulmonary Metastasis
RadiotherapyRadiotherapy

62. CHEMOTHERAPYCHEMOTHERAPY
 High dose Methotrexate with leucovorinHigh dose Methotrexate with leucovorin
 Doxorubicin(Adriamycin)Doxorubicin(Adriamycin)
 CisplatinCisplatin
 CarboplatinCarboplatin
 CyclophosphamideCyclophosphamide
 IfosfamideIfosfamide

63. WIDE RESECTIONWIDE RESECTION

64.  Wide excisionWide excision

65. RECONSTRUCTIONRECONSTRUCTION
 Autologous Bone GraftAutologous Bone Graft
 AllograftAllograft
 ProsthesisProsthesis
 RotationplastyRotationplasty

66. VAN NESS ROTATIONPLASTYVAN NESS ROTATIONPLASTY

67. VAN NESS ROTATIONPLASTYVAN NESS ROTATIONPLASTY

68. Van Ness RotationplastyVan Ness Rotationplasty

69. Amputation ProsthesisAmputation Prosthesis

70. Total Knee ProsthesisTotal Knee Prosthesis

72. EXPANDABLE CUSTOM MADEEXPANDABLE CUSTOM MADE
PROSTHESISPROSTHESIS

73. Humeral Prosthesis with AllograftHumeral Prosthesis with Allograft

74. Vascularized Fibular GraftVascularized Fibular Graft

76. Vascularized Fibular GraftVascularized Fibular Graft

79. PROGNOSISPROGNOSIS
 5 year Survival ranges from 60% to 85%5 year Survival ranges from 60% to 85%
 60 to 65% Treated 5 years ago (2000) will60 to 65% Treated 5 years ago (2000) will
be alive todaybe alive today
 Stage 1 Osteosarcoma has goodStage 1 Osteosarcoma has good
prognosis >90% just requiresprognosis >90% just requires
SurgerySurgery

80. PROGNOSISPROGNOSIS
 Stage 11b Prognosis dependsStage 11b Prognosis depends
1.1. Site of Tumor (worse for Axial Skeletal)Site of Tumor (worse for Axial Skeletal)
2.2. Size of Tumor Mass in cmSize of Tumor Mass in cm
3.3. Degree of necrosis from NeoadjuvantDegree of necrosis from Neoadjuvant
ChemotherapyChemotherapy

81. PROGNOSISPROGNOSIS
 Stage 111 with Lung Metastasis,Stage 111 with Lung Metastasis,
overall Prognosis is 30% depends onoverall Prognosis is 30% depends on
1.1. Resectability of primary tumor& LungResectability of primary tumor& Lung
NodulesNodules
2.2. Degree of Necrosis of primary TumorDegree of Necrosis of primary Tumor
3.3. Number of MetastasisNumber of Metastasis
4.4. Duration of development of MetastasisDuration of development of Metastasis