1. Osteosarcoma
1
04/23/13

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

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

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

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

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

7. Skeletal distribution
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8. Classification
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9. Clinical Presentation
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Painful mass arising from bone
Trauma
Metastisize early in evolution
 20% clinically detectable mets at dx

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

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

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

13. Local
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CT
MRI
+/- Angiogram

14. CT
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15. MRI
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16. Angio
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17. Systemic
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Bone scan
CT Chest
lab

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

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

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

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

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

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

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

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

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

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

28. 28

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

30. Current Standard of Care
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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

31. Surface osteosarcoma
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Parosteal
Periosteal
High grade surface osteosarcoma

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

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

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