ORTHOPAEDIC AND TRAUMATOLOGY DEPARTMENT

MEDICAL FACULTY OF HASANUDDIN UNIVERSITY

MAKASSAR
2021

PRIMARY BONE TUMOR DUE TUE

OSTEOSARCOMA
Presented by:
Nurul Ishla Ardy A C014182071

Advisors:
dr. Andi Firman Mubarak
dr. Putu Acarya

Supervisor:
dr. Muh. Phetrus Johan, M.kes, Ph.D, Sp.OT(K)
 PATIENT IDENTITY

Name : Nn. A
Age : 14 years old
Gender : Female
MR : 872013
Date of Adm.: February, 16th 2021
 ANAMNESIS
Chief Complaint : Lump on the left thigh
Patient comes with a complaint of a lump forming on the left thigh since 6 months ago.
At first the size of the lump was described as big as a tennis ball and progressively got bigger
in 2 months before time of admission. Pain is also felt espescially during walking and worsen
at night. There is a history of trauma where patient’s left knee hit a wall 1 month ago before
the lump forms, and recieved treatment from hospital and was prescribed anti pain medication,
There is a history where patient went to a massage therapist once. At this point the patient
went through 3 cycles of chemotherapy and the lump size have decreased.
There was a history of Weight loss
There was a history of fever
There was no history of prolong cough
There was no history of anti tuberculosis drugs consumtion
There were no history of family member with the same complaint
There were no history of suffering from other diseases
Patient went through incisional biopsy at 17/2/2021
PHYSICAL EXAMINATION
General status
Moderate illness/ E4V5M6 = Compos mentis

Vital signs :
 BP : 100/70 mmHg
 Pulse Rate : 92 x/minute(reguler),
 RR : 20 x/minute,
 T : 36.5º C

◦ Eye : Anemic Konjunctiva (+/+), Icteric Sclera (-/-)

◦ Lungs : Vesicular, no Crackles or Wheezing
◦ Jantung : Heart beat I/II pure reguler, no murmurs
◦ Abdomen : Normal Peristaltic , Liver and spleen not palpable
PHYSICAL EXAMINATION
Local status

Look: Deformity (+), Swelling (-), Hematoma (-), wound (-), venectasis (-),
lump (+) at distal femur as big as takraw ball.
Feel: lump with size 15x14cm, solitary, solid consistency, immobile, smooth
surface, temperature is warmer than surrounding, tenderness (+).
Move: Active and passive movements of the left knee joint cannot be evaluated
because of pain
NVD: Good sensibility, pulsation of the dorsalis pedis and posterior tibial
arteries palpable, capillary refill time less than 2 seconds
6
 Workup Diagnosis

Primary bone tumor left distal femur suspect malignancy

7
LABORATORY FINDINGS
Pemeriksaan Hasil Rujukan

WBC 9,0 4,00-10,0

RBC 4,01 4,00-6,00

HGB 10,7 12,0-16,0

PLT 354 150-400

PT 10,8 10-14

aPTT 28,3 22,0-30,0

GDS 98 140

Ureum 15 10-50

Creatinin 0,5 <1,1

SGOT 16 < 38

SGPT 9 < 41
 Radiologic Findings

Knee Sinistra AP + Lateral (May 7th 2021)

Impression :
 Characteristics of a Primary bone tumor distal os femur sinistra suggestive of osteosarkoma
 Osteopenia
 Radiologic Findings

Femur Sinistra AP + Lateral (May 7th 2021)

Impression :
 Characteristics of a Primary bone tumor distal os femur sinistra suggestive of
osteosarkoma
 Osteopenia
 Radiology Findings

Thorax PA + Lateral (May 17th 2021)

Kesan :
 No signs of metastasis on this thorax x-ray
 Cor and pulmo are within normal limits
 Radiology Findings
MSCT Scan Thorax non contrast (May 10th 2021)
Impression :
 No signs of metastasis on both lungs at this point
 Multiple lytic and blastic lesion at CV T3 to T9 Suggestive of
Tumour metastasis to the bone
MRI Genu sinistra non contrast (May10th 2021)
Impression :
 Primary bone tumor epimetadiafisis 1/3 distal os femur
sinistra according to the description of an osteosarkoma
 Histologic Findings

 Microscopic : Tumour cell with spindle core, very cellular

condensed chromatin core, prominent nuclei, rapid mitosis.
Tumour cell forms osteoid matrix.

Summary : OSTEOSARCOMA
 ASSESSMENT

- Primary bone tumor left distal femur due toe

osteosarcoma
 MANAGEMENT

• Ranitidin 50 mg/12 hrs/IV

• Ketorolac 30 mg/8 hrs/IV
• 3rd cycle Chemotherapy Regiment
 Cisplatin 72,5 mg/IV
 Adriamisin 36,25nmg/IV
 PLANNING
Wide excision + Cryotherapy
4th Cycle Chemotherapy with regiment
 Ivosfamid
 Adriamisin
LITERATURE REVIEW

17
 Definition
 Osteosarcoma is a spindle cell neoplasm that produces
osteoid.
 Osteosarcoma is a primary malignant tumor of bone
characterized by the formation of immature bone or osteoid
tissue by tumor cells.

Apley, A. Gaham. 2010. Buku Ajar Orthopedic Dan Fraktur Sistem Apply Edisi Kesembilan. Jakarta: Widya Medika
Picci P. 2007. Osteosarcoma (Osteogenic Sarcoma). Orphanet Journal of Rare Disease. http://www.OJRD.com/content/2/1/6, 1 Juli
2020.
 Epidemiology
 Age less than 20 years is 4.8 cases per one million population.
Highest at the age of 10-20 years.
 Osteosarcomas occur most often in long bone metaphysis, especially
in the distal femur (52%), proximal tibia (20%) where bone growth is
high. Another frequent site is the metaphysis of the proximal humerus
(9%). This disease usually spreads from metaphysis to diaphysis or
epiphyses.
 Osteosarcoma is more common in men, with a ratio of 3: 2 to women.

Apley, A. Gaham. 2010. Buku Ajar Orthopedic Dan Fraktur Sistem Apply Edisi Kesembilan. Jakarta: Widya Medika
Springfield D. 2006. Orthopaedics. dalam: Brunicardi FC. Schwartz’s Manual of Surgery 8th ed . USA: McGRAW-HILL.
Hide Geoff. 2008. Imaging in Classic Osteosarcoma. http://emedicine.medscape.com/article/393927-overview1 Juli 2020.
20
 Risk Factors

 Chemical Compounds
 Virus
 Radiation Exposure
 Genetics
 Other diseases i.e. Paget's Disease, Chronic Osteomyelitis,
Osteochondroma, Multiple Hereditary Exocytosis

Marulanda GA, Henderson ER, Johnson DA, Letson GD, Cheong D. Orthopedic surgery options for the treatment of primary
osteosarcoma. Cancer Control. 2008 Jan. 15(1):13-20.
 Classification
Based on histopatology :

Apley, A. Gaham. 2010. Buku Ajar Orthopedic Dan Fraktur Sistem Apply Edisi Kesembilan. Jakarta: Widya Medika
Enneking WF, Spanier SS, Goodman MA. Current concepts review. The surgical staging of musculoskeletal sarcoma. J Bone Joint
Surg Am. 1980 Sep. 62(6):1027-30.
 Grading

 In 1980 Enneking introduced a

stadium system based on degree,
extracompartmental distribution,
and the presence or absence of
metastases. This system can be used
on all musculoskeletal tumors (bone
and soft tissue tumors).

Marulanda GA, Henderson ER, Johnson DA, Letson GD, Cheong D. Orthopedic surgery options for the treatment of primary
osteosarcoma. Cancer Control. 2008 Jan. 15(1):13-20
National Cancer Institute. 2010. Osteosarkoma and Malignant Fibrous Histiocytoma of Bone Treatment . http://www.cancer.gov, 1 Juli
2020.
 Clinical Symptoms
• Symptoms usually occurs for several weeks or months before the
patient is diagnosed.
• The most common symptom is pain, especially pain during activity and
worse at night.
• Pain in extremities causes restriction of movement.
• A history of swelling may or may not exist.
• Other symptoms, such as fever, cough, backache, loss of appetite.

Apley, A. Gaham. 2010. Buku Ajar Orthopedic Dan Fraktur Sistem Apply Edisi Kesembilan. Jakarta: Widya Medika
Hide Geoff. 2008. Imaging in Classic Osteosarcoma. http://emedicine.medscape.com/article/393927-overview1 Juli 2020.
Enneking WF, Spanier SS, Goodman MA. Current concepts review. The surgical staging of musculoskeletal sarcoma. J Bone Joint
Surg Am. 1980 Sep. 62(6):1027-30.
 Clinical Symptoms

 Patient with osteosarcoma in the distal femur

Marulanda GA, Henderson ER, Johnson DA, Letson GD, Cheong D. Orthopedic surgery options for the treatment of primary
osteosarcoma. Cancer Control. 2008 Jan. 15(1):13-20
 Physical examination
• Findings on physical examination are usually limited to the
main site of the tumor.
• From Inspection, Examiner can identify the location of the
tumor, size of the mass, an increase in vascularity on the
skin, wound and active bleeding
• From Palpation, Examiner can found hard consistency,
undefined border
• Decreased range of motion in affected joints can be found
on physical examination

Marulanda GA, Henderson ER, Johnson DA, Letson GD, Cheong D. Orthopedic surgery options for the treatment of primary
osteosarcoma. Cancer Control. 2008 Jan. 15(1):13-20
 Laboratory investigation
 Most laboratory tests used are related to the use of chemotherapy. It is very
important to know the function of organs before giving chemotherapy and to
monitor organ function after chemotherapy.
 Some important laboratory tests include:
• LDH
• Complete blood count
• Liver function tests: Aspartate aminotransferase (AST), alanine
aminotransferase (ALT), bilirubin, and albumin.
• Electrolytes: Sodium, potassium, chloride, bicarbonate, calcium,
magnesium, phosphorus.
• Kidney function tests: blood urea nitrogen (BUN), creatinine

Marulanda GA, Henderson ER, Johnson DA, Letson GD, Cheong D. Orthopedic surgery options for the treatment of primary
osteosarcoma. Cancer Control. 2008 Jan. 15(1):13-20
 Radiology investigation
X-ray
Ct-scan
MRI
Bone scintigraphy

Hide Geoff. 2008. Imaging in Classic Osteosarcoma. http://emedicine.medscape.com/article/393927-overview1 Juli 2020.

Enneking WF, Spanier SS, Goodman MA. Current concepts review. The surgical staging of musculoskeletal sarcoma. J Bone Joint
Surg Am. 1980 Sep. 62(6):1027-30
 Radiology investigation

Plain photo of osteosarcoma with Codman

 Sunburst appearance in
triangle (arrow) and diffuse, osteoid
mineralization between soft tissues. Periosteal osteosarcoma in the distal
changes in the form of Codman triangles (white
arrow) and broad soft tissue mass (black arrow)
femur

Hide Geoff. 2008. Imaging in Classic Osteosarcoma. http://emedicine.medscape.com/article/393927-overview1 Juli 2020.

Enneking WF, Spanier SS, Goodman MA. Current concepts review. The surgical staging of musculoskeletal sarcoma. J Bone Joint
Surg Am. 1980 Sep. 62(6):1027-30
 Histopatology investigation

Biopsy is a definitive diagnosis for establishing

osteosarcoma. From histopathological picture we will found
stroma or high-grade sarcomatous with malognant osteoblast
cells, which will form osteoid tissue and bone. In the central
part there will be a lot of mineralization, while the peripheral
part will have less mineralization. Tumor cells are usually
anaplastic, with a pleomorphic nucleus and many mitoses

Hide Geoff. 2008. Imaging in Classic Osteosarcoma. http://emedicine.medscape.com/article/393927-overview1 Juli 2020.

Enneking WF, Spanier SS, Goodman MA. Current concepts review. The surgical staging of musculoskeletal sarcoma. J Bone Joint
Surg Am. 1980 Sep. 62(6):1027-30
 Treatment
Chemotherapy

 Chemotherapy reduces metastases to the lungs and, even if present, makes it

easier to excise them.
 Chemotherapy drugs that have quite effective results for osteosarcoma are:
doxorubicin (Adriamycin), cisplatin (Platinol), ifosfamide (Ifex), mesna
(Mesnex), and high dose methotrexate (Rheumatrex).
 Using this multi-agent treatment, with intensive doses, is proven to provide an
improvement in survival rates of up to 60 - 80%.

Kawiyana S. 2009. Osteosarcoma, Diagnosis dan Penanganannya. http://ejournal.unud.ac.id/abstrak/dr%20siki_9.pdf , 1 Juli 2020.

 Treatment
Surgery
 The main purpose of resection is patient safety.
 The two primary surgical options are tumor excision
with limb salvage and amputation.
 The results of the combination of chemotherapy with
resection look better when compared to radical
amputation without adjuvant therapy, with a 5-year
survival rate of 50-70% and 20% in treatment with only
radical amputation.
 Surgical resection of the primary osteosarcoma is
generally performed 3 to 4 weeks after the last dose of
preoperative chemotherapy. Postoperative
chemotherapy is begun 2 weeks after surgical resection,
provided that the surgical wound has completely healed.

Marulanda GA, Henderson ER, Johnson DA, Letson GD, Cheong D. Orthopedic
surgery options for the treatment of primary osteosarcoma. Cancer Control. 2008 Jan.
15(1):13-20
 Prognosis
.

• The 5-year survival rates for patients with >90% tumor necrosis are reported to be
>61%, but drop to 37% to 52% in patients with a poor response (<90% necrosis).

• Assessment of Huvos scores to histologically evaluate neo-adjuvant chemotherapy

responses. Assessment is done semi-quantitatively by comparing the extent of the
necrosis area to the rest of the tumor:
1) Grade1: little or no necrosis (0-50%)
2) Grade2: necrosis> 50 - <90%
3) Grade3: 90-99% necrosis
4) Grade4: 100% necrosis

National Cancer Institute. 2010. Osteosarkoma and Malignant Fibrous Histiocytoma of Bone Treatment . http://www.cancer.gov, 1 Juli
2020.
THANK YOU