ELBOW RECONSTRUCTION FOR DISTAL HUMERUS OSTEOSARCOMA

BY USING EXTRACORPOREAL IRRADIATION AUTOGRAFT (TWO

CASE REPORTS)

By Yanuarso, A Fauzi K, Errol Untung Hutagalung

Division of Orthopaedic and Traumatology

Faculty of Medicine
University of Indonesia

Introduction

Malignant bone tumors are rare lesions :

- RSCM →1,3% of all the cancer load
(Errol UH, unpublished data, 2006)
- Mayo Clinic → 1-2%

Osteosarcoma → the 2nd common malignant bone tumors after multiple myeloma → 19%
(Dahlin’s bone tumors general aspects and data on 11,087 cases.1996. pp.143-95)

Before 1970s
→ the routine management was amputations or disarticulation
→ survival rate 10-20%

Limb salvage surgery

→ combination of :
- Effective chemotherapies
- Precision imaging techniques
→ designed to accomplish removal of a malignant tumor and reconstruction of the limb with an
acceptable oncologic, functional, and cosmetic result

J Am Acad Orthop Surg 2003;11:25-37

Local status
Mass :
- 26 cm in circumferential length (20 cm in the health tissue)
- Firm, tenderness, fixed with ill-defined margin
Laboratory
- CBC : normal
- ESR : 29mm/h
- SAP : 161 u/l (40 – 150)
- LDH : 303 u/m (230–460)

Left elbow AP and lateral X-ray (January 2006) :

- Blastic and lytic lesions in the left distal humerus
- Periosteal reaction and soft tissue swelling

After neoadjuvant chemotherapy

→ tumor became more sclerotic & solid

Chest X-Ray : no evidence of metastatic feature

Bone scintigraphy : increased uptake only at the left elbow
→ Neither showed no evidence of metastatic disease
 CT scan :
- Lytic-sclerotic lesion with irregular margin
- Thickening of cortex and periosteal
- New bone formation and good medullary cavity

Cytology examination :
Spindle cells, pleomorphic with osteoid positif
Photo 11

Clinico Pathological Conference (CPC)

- Diagnosed as conventional osteosarcoma → neoadjuvant chemotherapy
- Planned for limb salvage surgery using an extracorporeal irradiation of distal humerus

First Stage :
- Resection of the half distal humerus that contain tumor mass → Pathology
Anatomy Department

- Osteotomy of olecranon

- Conservation of n.radial, n.ulnar & muscle groups, except the part of the triceps
& brachialis attached to the tumor mass

- The resected humerus was sent to BATAN for irradiation with dose 30,000 rads
Second Stage :
- Reconstruction of the half distal humerus with plate and screw
- Olecranon fixation with TBW
- Sutured common flexor & extensor origins to the original sites

- Histological examination of the surgical specimen:

So much residual viable tumor cells and the tumor classified as unresponder to the induction
chemotherapeutic agents (HUVOS 1)
- After surgery → patient was planned to received adjuvant chemotherapy consisting of another
agents

SECOND CASE

Local Status :

Mass :

- 32 cm in circumferential length (23 cm in the health tissue)

- Firm, tenderness, fixed with ill-defined margin
- No venectation

Laboratory

- CBC : normal
- ESR 30 mm/h
- SAP 192 u/l (40–150)
- LDH : 165 u/m (230–460)

X-ray of left elbow AP and lateral views (May 2006) :

→ heavily mineralized mass attached by broad base to the posterior
aspect of left distal humerus and soft tissue swelling

- Chest X-Ray : no evidence of metastatic feature

- Bone scintigraphy : inceased uptake only at the left elbow
→ No evidence of metastatic disease

Review slide from first operation :

Spindle cells, minimal cytologic atypia and rare mitotic
figure, osteoid positif

Clinico Pathological Conference (CPC)

- Diagnosed as reccurrent parosteal osteosarcoma
- Planned to limb salvage procedure using extra corporeal
irradiation autograft
- Death : Nov 2007
 First Stage :
- Resection of the half distal humerus and excision of
the tumor mass → sent to Pathology Anatomy Dep.
- Resected humerus → BATAN for irradiation 30,000
rads

Second Stage :

- Reconstruction of the half distal humerus and elbow by fixed them into the
proximal shaft with plate and screw

- Olecranon was fixed with the tension band wire

- Common flexor and extensor origins were sutered again to the original sites

- Radiohumeral joint was fixed with the K wire for temporary

 Post-operative X rays :
Humeral shaft fixed with plate and screw and olecranon fixed with TBW

Discussion
- Primary malignant bone tumors → rare lesions
- Before 1970s → routine management was consisted of transbone amputations or disarticulation

→ dismal survival rate 10-20%

Dahlin’s bone tumors general aspects and data on 11,087 cases.1996. pp.143-95.
J Am Acad Orthop Surg 2003;11:25-37. hal. 24

Development of :
- Effective chemotherapeutic agents
- CT and MRI
- Allow precise visualization of the anatomic location of
tumor and surrounding structures
- Better patient selection for spesific treatment of limb
salvage procedure
JAm Acad Orthop Surg 2003;11:25-37.

Consideration of Limb Salvage Procedure :

1. An upper extremity tumor → needs resection of the
articular portion of the distal humerus or proximal ulna
2. Disfunction of the elbow, wrist, and hand → due to
abundant of neurovascular structures in this location
3. Psychological problem associated with tradition and
aesthetic
J Bone Joint Surg [Br] 1996;78-B:652-57 hal 26
Conclusion
- The management of malignant bone tumors still presents many challenge
- Advances in imaging, chemotherapy and reconstructive surgery can offered
limb sparing surgery
- Functional outcome and patient satisfaction appear to be at least as good,
and probably better after reconstruction than after ablation