It is a presentation covering all the important aspects of the 2nd most common tumor, osteosarcoma in extensive details.

1. OSTEOSARCOMA

2. INTRODUCTION
• 20% OF ALL PRIMARY BONE TUMOR
• SECOND-MOST COMMON PRIMARY MALIGNANCY
OF BONE
• INCIDENCE: 1 TO 3 PER MILLION PER YEAR
• MALE: FEMALE—1.6:1(EXCEPT PAROSTEAL
VARIETY)
• AGE: CONVENTIONAL—2ND DECADE

3. SITE
AROUD THE KNEE JT.(ARISING MAINLY FROM
METAPHYSIS;INTRAMEDULLARY REGION)
52% --LOWER END OF FEMUR
20%-- UPPER END OF TIBIA
9% -- UPPER END OF HUMERUS

4. PREDISPOSING FACTORS :
• RADIATION
• VIRAL INFECTION: PLYOMA VIRUS/HARVEY
VIRUS
• CHEMICALS:BERYLLIUM 20-METHYL
CHOLANTHRENE

5. CLINICAL FEATURES
• PRESENTING FEATURES:
- PAIN(NIGHT PAIN)
-SOMETIMES ONLY TIREDNESS & LIMP
-PALPABLE MASS
-SKIN CONDITIONS TO BE EXAMINED
CAREFULLY
• H/O TRAUMA SOMETIMES DRAWS ATTENTION

6. ASSOCIATED FEATURES
• EFFUSION & SWELLING OF NEARBY JOINTS
• FEVER
• PALLOR & CACHEXIA
• REGIONAL LN
• FEATURES ASSOCIATED WITH PULMONARY
METASTASIS
• PATHOLOGICAL #

7. OSTEOSARCOMA

8. CONTD….
DISTAL NEUROVASCULAR DEFICITS
AND PRESSURE SYMPTOMS
….MAY BE ASSOCIATED WITH

9. CLASSIFICATION
• PRIMARY OSTEOSARCOMA
• SECONDARY OSTEOSARCOMA

10. CLASSIFICATION: WHO
(PRIMARY OSTEOSARCOMA)
• CENTRAL(MEDULLARY)
• SURFACE(PERIPHERAL)

11. CENTRAL(MEDULLARY)
• CONVENTIONAL
• TELANGIECTATIC
• INTRAOSSEOUS/INTAMEDULLARY
(WELL-DIFFERENTIATED/LOW-GRADE)
• SMALL CELL OSTEOSARCOMA

12. SURFACE(PERIPHERAL)
• PAROSTEAL(LOW-GRADE)
• PERIOSTEAL(LOW TO INTERMEDIATE GRADE)
• HIGH-GRADE SURFACE OSTEOSARCOMA

13. SECONDARY OSTEOSARCOMA
-PAGET’S DISEASE
-RADIATION
-BENIGN PRE-EXISTING
CONDITIONS
[OSTEOCHONDROMA

14. SECONDARY OSTEOSARCOMA
• OLDER AGE GROUP
• PROGNOSIS POOR
• LONG HO DULL ACHING PAIN&RECENT
LYTIC DESTRUCTION

15. PATHOLOGY: MACROSCOPY
Typical osteosarcoma presents as a large illdefined lesion in the metaphyseal region of
the involved bone. It typically destroys cortex
and frequently extends inwards marrow
cavity and outwards into the adjacent soft
tissue.

16. PATHOLOGY: MACROSCOPY
Tumour often elevates periosteum to
produce codman’s triangle on radiograph. It
also produces sunray appearance due to
vessels which pass from the periosteum to
the cortex & along which bone is laid down
& some of the new bone may be reactionary

17. PATHOLOGY: MACROSCOPY
• LARGE ILL-DEFINED LESION IN THE
METAPHYSEAL REGION OF LONG BONE
• LEG OF MUTTON’ APPEARANCE
• STONY-HARD TO SOFT AND GRITTY IN
CONSISTENCY
• AREAS OF HAEMORRHAGE & NECROSIS
• COLOUR: WHITE
:
YELLOW
:
BLUISH WHITE:
FIBROBLASTIC
OSTEOBLASTIC
CARTILAGENOUS

19. CONTD…
• CODMAN’S TRIANGLE ---DUE TO
SUBPERIOSTEAL NEW BONE FORMATION
• SUNRAY APPEARANCE ---DUE TO BONE
DEPOSITION IN SUB-PERIOSTEAL SPACE
ALONG THE VESSELS

20. SUNRAY APPEARENCE

21. PATHOLOGY:MICROSCOPY
LICHTENSTEN’S CRITERIA TO IDENTIFY
OSTEOSARCOMA :
1)SARCOMATOUS STROMA
2)SPINDLE CELLS.
3) DIRECT FORMATION OF NEOPLASTIC
OSTEOID AND BONE.

22. PATHOLOGY:MICROSCOPY
Hallmark of osteosarcoma is the formation
of osteoid by malignant mesenchymal cells .
The neoplastic mesenchymal cells in
between osteoid & cartilage elements may
be spindle shaped and pleomorphic with
bizarre hyperchromatic nuclei and frequent
mitotic figures. Giant cells may be present.

23. RADIOLOGIC INVESTIGATIONS
• PLAIN RADIOGRAPH(X-RAY)
• CT SCAN
• MRI SCAN
• BONE SCAN

24. RADIOLOGY
• ARISES IN THE METAPHYSIAL REGION OF A
LONG BONE
• OUTGROWS FROM THE MEDULLARY CANAL
TO EXTRASKELETAL REGION
• DISPLAYS REPRESENTATIVE FEATURES OF A
MALIGNANT LESION- PERMEATIVE GROWTH
PATTERN/INDISTINCT MARGINS/CORTICAL EROSION

25. RADIOLOGY..
• PERIOSTEAL REACTION WITH FORMATION OF
CODMAN’S TRIANGLE/SUNBURST APPEARANCE
• WIDE VARIETY OF RADIOGRAPHIC APPEARANCE
LIKE BONE CYST

26. RADIOLOGY..
• CT SCAN AND MRI SCAN ARE NOT AS
INSTRUMENTAL AS PLAIN RADIOGRAPH
• BONE SCAN IS USEFUL TO DETECT
METASTASIS

27. RADIOLOGY..MRI SCAN
• EXCELLENT FOR DESCRIBING LESIONS IN THE
MARROW CAVITY
• HELPFUL TO DETERMINE THE LEVEL OF RESECTION
• USEFUL FOR SCREENING SKIP LESIONS
• CAN DETECT MEDULLARY INVASION IN CASE OF
JUXTACORTICAL TUMORS
• CAN DETECT EPIPHYSEAL INVOLVEMENT AND
PENETRATION OF PHYSEAL CARTILAGE

28. DIAGNOSIS
•
•
•
•
•
HISTORY
CLINICAL EXAMINATION
HAEMATOLOGY
RADIOLOGICAL INVESTIGATIONS
HISTOPATHOLOGIC EXAMINATION

29. MANAGEMENT: MULTIDISCIPLINARY
APPROACH
PRIMARY CARE PHYSICIAN
ORTHOPAEDIC SURGEON
RADIATION ONCOLOGIST
PATHOLOGIST
PHYSIOTHERAPIST
REHABILITATION SPECIALIST
SOCIAL WORKERS & OTHERS

30. TREATMENT OPTIONS
• CHEMOTHERAPY
• SURGERY
• RADIOTHERAPY

31. CHEMOTHERAPY
• Introduction of systemic chemotherapy has
dramatically improved survival rates.
• Before the routine use of chemotherapy—
treatment was immediate wide or radical
amputation
• 80% patients died of metastasis eventually,
though metastasis was not evident on
presentation.

32. CHEMOTHERAPY
• NEO-ADJUVANT CHEMOTHERAPY:
CT ADMINISTERED BEFORE THE SURGICAL
RESECTION OF PRIMARY TUMOUR
• ADJUVANT CHEMOTHERAPY:
CT ADMINISTERED POSTOPERATIVELY TO TREAT
PRESUMED MICRO-METASTASIS

33. NEO-ADJUVANT CHEMOTHERAPY
• IT SHRINKS THE TUMOUR MASS , MAKING IT EASIER
FOR OPERATION
• IT DECREASES THE SPREAD OF TUMOUR CELLS
DURING SURGERY,
• T/T AGAINST POTENTIAL MICRO-METASTASIS
STARTED IMMEDIATELY,
(IT ALSO GIVES IDEA ABOUT RESPONSIVENESS &
EFFECTIVENESS OF THE CHEMOTHERAPEUTIC
AGENT TO THE TUMOUR)

34. NEO-ADJUVANT CHEMOTHERAPY
DISADVANTAGES…
• IT MAY INCREASE PERI-OPERATIVE
COMPLICATIONS(DELAYED WOUND HEALING,
INFECTION)
• NAUSEA, VOMITING AND OTHER TOXICITIES
MAY CAUSE DELAY IN SURGERY.

35. MANAGEMENT…
LOW GRADE OSTEOSARCOMA-- TREATED BY
SURGERY ALONE.
HIGH GRADE OSTEOSARCOMA-- TREATED BY
NEO-ADJUVANT CHEMOTHERAPY
SURGERY 
ADJUVANT CHEMOTHERAPY,

36. MANAGEMENT…
AFTER INDUCTION OF CHEMOTHERAPY(LASTING
ABOUT 2 MONTHS) SURGICAL RESECTION IS TO BE
CARRIED OUT.
SURGERY IS CONTEMPLATED 3-4 WEEKS AFTER LAST
DOSE OF CHEMOTHERAPEUTIC AGENT
ADJUVANT CHEMOTHERAPY AGAIN STARTED 2
WEEKS AFTER OPERATION

37. COMMON AGENTS USED
DOXORUBICIN – 60-75 MG/M²
CARDIOTOXICITY,
CISPLATIN -- 50-100 MG /M²
NEPHROTOXICITY
VINCRISTINE -- 1.5 MG /M²,WEEKLY
PERIPHERAL NEUROPATHY
METHOTREXATE – 500-1000 MG/M² IV
MEGALOBLASTIC ANAEMIA,
PANCYTOPENIA

38. CONTD…
CYCLOPHOSPHAMIDE &
IFOSFAMIDE -- 1-1.5 G/M² B S A
HAEMORRHAGIC CYSTITIS
DACARBAZINE –250MG/M²BSA
FLU LIKE SYNDROME
DACTINOMYCIN – ERYTHEMA
MYELOSUPPRESION

39. CONTD…
ROUTE OF ADMINISTRATION –
• INTRAVENOUS –
• ORAL & INTRAMUSCULAR –
• INTRA ARTERIAL –

40. INTRA-ARTERIAL ADM OF
CHEMOTHERAPY
• HIGHER CYTOTOXIC CONC. DIRECTED AGAINST
TARGET TISSUE
• CISPLATIN – MOST SUCCESSFUL AGENT
• INFLUENCING FACTORS —
PRETREATMENT ANGIOGRAPHY,
CATHETER PLACEMENT,

41. RESPONSE TO PREOPERATIVE
CHEMOTHERAPY ASSESSED BY
• CLINICAL
• RADIOGRAPHIC
• ANGIOGRAPHIC
• PATHOLOGICAL PARAMETERS

42. RADIATION THERAPY
• ROLE OF RADIOTHERAPY IS LIMITED IN THE
TREATMENT OF OSTEO-SARCOMA --A RELATIVELY
RADIO-RESISTANT TUMOR.
• RADIATION THERAPY CAN PALLIATE PAIN FROM
LOCAL RECURRENCE AND PREVENT NEED FOR
AMPUTATION IN PATIENTS WHO ARE PRESENTED
WITH DISTANT METASTASIS

43. RADIATION THERAPY INDICATIONS
• POST-OPERATIVE -- WHERE SURGICAL MARGIN IS
INVOLVED
• PALLIATION OF PAIN FROM PRIMARY TUMOUR IN
THE PRESENCE OF METASTATIC DISEASE
• RADICAL TREATMENT OF INOPERABLE SITES
(SKULL, VERTEBRA, ILIUM, SACRUM)
• BILATERAL LUNG IRRADIATION IN PULMONARY
METASTASIS

44. RADIATION THERAPY
• EXTERNAL BEAM RADIATION — BY LINEAR
ACCELERETER.
• BRACHYTHERAPY —LIMITED ROLE
• IORT – SINGLE DOSE,IN SPECIALLY PREPARED OT

45. RADIATION THERAPY
• AC. SIDE EFFECTS— SKIN REACTION
MILD FATIGUE
ANOREXIA
ALTERED SLEEP & REST CYCLE
• LATE EFFECTS — LYMPHATIC & VASCULAR OBST.
OSTEO-NECROSIS
JOINT STIFFNESS
RADIATION INDUCED
SARCOMAS

46. SURGERY
SURGERY IS THE MAINSTAY OF THERAPY
• LIMB SACRIFICING SURGERY OR
• LIMB SALVAGING SURGERY
?

47. PRINCIPLES OF SURGERY
CHOICE BETWEEN LIMB SALVAGE SURGERY AND
AMPUTATION MUST BE MADE ON THE BASIS OF
THE EXPECTATIONS AND DESIRES OF THE
INDIVIDUAL PATIENT AND THE FAMILY.

48. PRINCIPLES OF SURGERY
POINTS TO BE STRESSED
• SURVIVAL AFTER THE PROCEDURES
• SHORT AND LONG TERM MORBIDITY
• FUNCTION OF SALVAGED LIMB COMPARED TO
PROSTHETICS
• PSYCHOSOCIAL CONSEQUENCES

49. PRINCIPLES OF SURGERY
ADVANCES IN
DIAGNOSTIC IMAGING
CHEMOTHERAPY (NEO-ADJUVANT
CHEMOTHERAPY)
SURGICAL TECHNIQUES
…….HAVE MADE
LIMB SALVAGE SURGERY……
A REASONABLE OPTION

50. LIMB SALVAGE SURGERY
“SURGICAL PROCEDURES DESIGNED TO
ACCOMPLISH REMOVAL OF MALIGNANT
TUMOURS & RECONSTRUCTION OF THE LIMB
WITH AN ACCEPTABLE ONCOLOGIC, FUNCTIONAL
& COSMETIC RESULTS.”

51. LIMB SALVAGE SURGERY
• NEW SURGICAL TECHNIQUES.
• PROGNOSIS IMPROVED GREATLY.

52. LIMB SALVAGE SURGERY
THREE IMPORTANT DEVELOPMENTS
1. Improvement in chemotherapy — In early
70s methotrexate and adriamycin was
introduced.
2. Improvement in imaging techniques—
development of CT & MRI in late 70s.
3. Advances in micro- surgical techniques

53. GUIDELINES
• NO INVOLVEMENT OF MAJOR NEUROVASCULAR
STRUCTURES
• WIDE RESECTION OF AFFECTED BONE WITH A NORMAL
MUSCLE CUFF ALL AROUND
• EN-BLOCK REMOVAL OF ALL BIOPSY SITES &
CONTAMINATED TISSUE

54. GUIDELINES (contd.)
• RESECTION OF BONE 3-4 CM BEYOND ABNORMAL
UPTAKE
• RESECTION OF ADJOINING JOINT & CAPSULE.
• ADEQUATE MOTOR RECONSTRUCTION
• ADEQUATE SOFT TISSUE COVERAGE.

55. SURGICAL MARGINS IN ONCOLOGY

56. METHODS
• BONE GRAFTING
AUTOLOGUS GRAFT : VASCULARISED
GRAFT
ALLOGENIC GRAFT : BONE BANK
• ROTATIONPLASTY
• RESECTION/ARTHRODESIS
• PROSTHESIS
• COMPOSITE
ALLOGRAFT PROSTHETIC COMPOSITES

57. CONTRAINDICATIONS
• DISPLACED PATHOLOGICAL FRACTURE
•
INAPPROPRIATE BIOPSY SITE
•
INFECTION
•
SKELETAL IMMATURITY
•
MAJOR NEUROVASCULAR INVOLVEMENT
•
EXTENSIVE MUSCLE INVOLVEMENT

58. LIMB SALVAGE SURGERY…
• LIMB SALVAGE SURGERY HAS BECOME AN
ACCEPTED STANDARD OF CARE FOR PATIENTS WITH
SKELETAL MALIGNANCIES INCLUDING
OSTEOSARCOMA
• MANY PATIENTS WHO ONCE WOULD HAVE HAD AN
AMPUTATION ARE NOW HAVING THEIR LIMB SAVED

59. TREATMENT OF
• PULMONARY METASTASIS
• LOCAL RECURRENCE
• SECONDARY DISEASE

60. PRONOSTIC FACTORS
•
•
•
•
•
•
•
EXTENT OF DISEASE AT THE TIME OF DIAGNOSIS
GRADE OF THE LESION
SIZE OF THE TUMOUR
LOCATION OF THE TUMOUR
PAGET’S SARCOMA
RADIATION INDUCED SARCOMA
RADIATION INDUCED NECROSIS

61. THANK YOU