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Osteosarcoma

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  1. Osteosarcoma Paul Duffy

  2. Definition Epidemiology Pathogenesis Skeletal distribution Clinical presentation Evaluation High grade osteosarcoma Parosteal osteosarcoma Periosteal osteosarcoma High grade surface osteosarcoma Overview

  3. Definition • 2nd most common primary bone tumor • Malignant tumor of mesenchymal origin • Spindle shaped cells that produce osteoid

  4. Epidemiology • Any age • 75% 12-25yrs • Modal incidence

  5. Epidemiology • Primary vs secondary • Male : female • Li Fraunie syndrome

  6. Pathogenesis • Unknown • Modal incidence correlates with rapid bone growth • Radiation exposure • Cancer survivors • Retinoblastoma

  7. Skeletal distribution

  8. Classification

  9. Clinical Presentation • Painful mass arising from bone • Trauma • Metastisize early in evolution • 20% clinically detectable mets at dx

  10. Evaluation • Suspected diagnosis by hx and physical • Supported by xray

  11. Plain Xray • Lytic, sclerotic or mixed • Typical characteristics of malignant tumor • Enneking’s 4 questions

  12. Initial Evaluation • Define the extent of the disease • Locally • Systemically

  13. Local • CT • MRI • +/- Angiogram

  14. CT

  15. MRI

  16. Angio

  17. Systemic • Bone scan • CT Chest • lab

  18. Classic High Grade Osteosarc • Age, sex • Presentation • Physical exam • Blood work • Plain films • Site • size

  19. Differential Dx • Giant Cell Tumor • Aneursymal Bone Cyst • Ewings • Osteoblastoma • Metastasis • Lymphoma

  20. Biopsy • Principles • Dx “high grade osteosarcoma” • Now What??

  21. Chemotherapy • Micro metastasis • What we have learned pre chemo (1970’s) • Multi Institutional Osteosarcoma Study

  22. Chemotherapy • Chemo cannot control clinically detectable disease • Radiation is ineffective • Local control is surgical

  23. Chemotherapy • Best protocol is subject of ongoing trials • Drugs • Doxorubicin • Cisplatin • Ifosfamide • Methotrexate • Cyclophosphamide • Side effects

  24. Induction Chemotherapy • Arose in conjunction with development of limb sparing surgery • Increase survival • prognostic

  25. Surgery • Limb salvage the norm • Now safer procedure • Wide surgical margin

  26. Surgical options • Articular surface removed • Osteoarticular allograft replacement • Custom modular prosthesis • Allograft prosthesis composite • Allograft arthodesis • Segment of diaphysis missing • Intercalary allograft

  27. Surgery • Young patient with open growth plate • Rotatioplasty • Conventional amputation

  28. Surgery • Indication for amputation • Grossly displaced pathologic fracture • Encasement of neurovascular bundle • Tumor that enlarges during preop chemo and is adjacent to neurovascular bundle

  29. Current Standard of Care • Pretreatment radiologic staging • Bx to confirm diagnosis • Preoperative chemotherapy • Repeat radiologic staging • (access chemo response, finalize surgical tx plan) • Surgical resection with wide margin • Reconstruction using one of many technoques • Post op chemo based on preop response

  30. Surface osteosarcoma • Parosteal • Periosteal • High grade surface osteosarcoma

  31. Parosteal • 5% of osteosarcomas • Posterior metaphysis of distal femur • Slow growing large ossified mass • Confused with osteochondroma • String sign • Low grade • treatment

  32. Parosteal Osteosarcoma

  33. Parosteal Osteosarcoma

  34. Periosteal Osteosarcoma • Arises from surface of diaphysis • Characterized by bony spicule formation perpendicular to shaft • Sunburst • Low grade • Wide excision

  35. High grade surface • Very rare • 20-30’s • Appearance as parosteal but histology high grade • Tx as classic intermedullary