Osteosarcoma: An Introduction

What is osteosarcoma?

Osteosarcoma is a type of cancer that produces immature bone. It is the most common type of
cancer that arises in bones, and it is usually found at the end of long bones, often around the
knee. Most people diagnosed with osteosarcoma are under the age of 25, and it is thought to
occur more often in males than females.

Osteosarcomas range from low grade tumors that only require surgery to high grade tumors that
require an aggressive treatment regimen. Patients with osteosarcoma are best treated at a cancer
center where an expert sarcoma team and resources are available to provide specialized and
responsive care.

What causes osteosarcoma?

Scientists have not discovered the cause of most cases of osteosarcoma. Osteosarcoma can
develop as a result of radiation to an area of the body. It can also be associated with specific
genetic changes and diseases.

What are the symptoms of osteosarcoma?

Most people with osteosarcoma do not feel sick. Patients may have a history of pain in the affected
area and may have developed a limp. Often the pain is thought to be related to muscle soreness
or "growing pains," but it does not go away with rest. Many patients only see a doctor when there
is some sort of injury to the area or when the tumor weakens a bone so much that it breaks (this
is called a pathological fracture).

How is osteosarcoma diagnosed?

An x-ray is often the first diagnostic test that osteosarcoma patients receive, and an experienced
radiologist may recognize immediately that bone cancer is the likely diagnosis. There are several
additional tests that are a critical part of osteosarcoma diagnosis and staging:

 An MRI of the entire bone where the primary tumor is located. This test can rule out "skip
metastases" (spread of the tumor to other areas of the bone).
 A chest x-ray and CT scan of the chest to detect lung metastases
 A bone scan of the body to rule out distant spread of the disease
 A biopsy of the tumor, which provides a definite diagnosis based on the characteristics of tumor
tissue seen under a microscope. The biopsy will also show whether the tumor is high grade (highly
malignant, which is the case for most osteosarcomas) or low grade.
There are two main types of biopsy: a needle aspiration and a surgical biopsy. The location,
incision and technical aspects of the biopsy can affect a patient’s treatment options and outcome.
Therefore, it is essential that the biopsy is planned by a surgeon experienced with sarcomas.
The results of the biopsy and imaging studies provide physicians with an idea of the "personality,"
or stage, of the disease. Most patients are diagnosed with high grade disease that does not
appear to have spread throughout the body. However, it is believed that about 80% of patients
with high grade osteosarcoma already have metastatic disease that is not yet visible on imaging
tests.

How is osteosarcoma treated?

Osteosarcoma is often treated with a combination of therapies that can include surgery,
chemotherapy and radiation therapy. Most patients with high grade tumors receive about three
months of chemotherapy, known as neo-adjuvant therapy, before surgery. A surgeon will then
remove the tumor, along with a wide margin of healthy tissue around the tumor, with the goal of
leaving the area free of all disease.

Most tumors at the bones and joints can be removed safely while sparing the involved limb. A
surgeon might use a metal implant, an allograft (bone taken from a cadaver), a combination of an
implant and allograft, or a bone taken from the patient in order to replace tissues that are removed
during surgery. Occasionally, because of a tumor’s size or location, an amputation or
rotationplasty is the best way to completely remove the cancer and restore the patient to a
functional life.

When considering surgical options, it is important that the patient and surgeon talk about the
expected functional results of each option and the possible complications and risks involved. It
may be in the patient’s best interest to ask a surgeon how many procedures he or she has done
that involve a specific joint and to seek a second opinion from a surgeon who has more experience
performing a specific surgery. Overall, patients who have limb salvage surgery and those who
have amputation report similar rates of satisfaction and function after their recovery, but these
rates vary greatly from one person to the next.

After surgery, a pathologist will report the tumor’s necrosis rate (the percentage of tumor cells that
are dead), which is an indicator of how well the tumor is responding to the chemotherapy. Based
on the necrosis rate, drugs are chosen for additional chemotherapy treatment, which normally
lasts about six months after surgery.

Though radiation therapy is not widely used in osteosarcoma treatment, it can be effective and is
occasionally recommended, especially when a tumor is difficult to remove surgically or when
residual tumor cells remain after surgery.

Tests are done to monitor each patient’s health during treatment, with a focus on the heart,
kidneys and liver. Some patients are also given scans that can indicate a tumor’s response to
therapy. Because each individual responds differently, there may be significant changes to a
patient’s treatment plan along the way.

What is the prognosis for osteosarcoma patients?

Prognosis statistics are based on the study of groups of osteosarcoma patients. These statistics
cannot predict the future of an individual patient, but they can be useful in considering the most
appropriate treatment and follow-up for a patient.

When treated appropriately, patients with high grade osteosarcoma in one location have a survival
rate of about 70%. The survival rate is higher for patients with low grade tumors, and it is lower
for those whose disease has spread throughout the body and for those whose tumors have a
poor response to chemotherapy.

How are patients followed after treatment?

The National Comprehensive Cancer Network recommends a schedule of follow-up exams and
tests for osteosarcoma patients. It includes appointments every three months for the first two
years, every four months for the third year, every six months for the fourth and fifth year, and
annually thereafter. Most appointments include a physical exam, imagining of the original tumor’s
location and imaging of the lungs. In patients who have been treated with chemotherapy, tests
are also done periodically to monitor the heart, liver and kidneys; to test for hearing loss and to
check hormone levels, bone density and cholesterol. If recurrence is detected at follow-up, further
chemotherapy and/or surgery is usually recommended.
http://sarcomahelp.org/osteosarcoma.html#tpm1_1
Osteosarcoma

BY DAISY JANE ANTIPUESTO RN MN · OCTOBER 5, 2010

 Type of bone cancer that develops in the cells (forms the outer covering of the bone).
 Most common and fatal in children and males between 10-25 years old.
 5% of all childhood cancers.
 Common sites: long bones, knee, upper leg, thigh bone, lower leg and upper arm.
Etiology
Causes:
 Unknown
 DNA mutation – either inherited or acquired after birth.
 Familial susceptibility
 Injury
 Infection
 Metabolic or hormonal disturbance
Risk Factors:
Children
 Teenage growth spurt
 Tall for the age
 Previous treatment with radiation
 Benign and non-cancerous bone tumors
 Retinoblastoma
Adult
 High fat diet
 Lack of exercise
 Smoking
 Drinking alcohol
Pathophysiology
1. Osteoblast
2. DNA mutation
3. Malignant osteoblast (abnormal)
4. Proliferation of abnormal osteoblast
5. Formation of osteoid or immature bone
6. Signs and symptoms are then observed such as pain, swelling, and tenderness.
Assessment
1. Encourage patient to discuss problem and course of symptoms.
2. Note patient and family’s understanding of the disease, coping with the problem and
management of pain.
3. Palpate mass gently on physical examination.
4. Note size and associated soft-tissue swelling, pain and tenderness of the mass.
5. Assess neuromascular status and range of motion extremity.
6. Evaluate motility and ability to perform activities of daily living.
Diagnostic Procedures
 X-ray
 MRI
 CT scan
 Biopsy
 CBC
 Blood chemistry
 Urine analysis
 Sternal marrow puncture
Nursing Diagnosis
 Acute or chronic pain
 Risk for injury: pathologic fracture related to tumor
 Ineffective coping
 Activity intolerance
Nursing Intervention
1. Provide quiet environment and calm activities to prevent or lessen pain.
2. Provide comfort measure such as back rub, change position and use of heat or cold
application.
3. Encourage diversional activities
4. Administer analgesics as indicated to maximal dose as needed.
5. Encourage the patient to increase fluid intake.
6. Encourage rest periods to prevent fatigue.
7. Provide accurate information about the situation, medication and treatment.
8. Assess muscle strength, gross and fine motor coordination.
9. Provide pillows for cushion and support.
10. Keep side rails up all the time.
Complications
 Alopecia
 Reduction in number of leucocytes and platelets
 Septicemia
 Bleeding
 Anemia
 Kidney damage
 Hearing loss

Pathophysiology
Osteosarcoma is a bone tumor that can occur in any bone. It most commonly occurs in the long
bones of the extremities near metaphyseal growth plates. The most common sites include the
femur (42%), with 75% of tumors in the distal femur; tibia (19%), with 80% of tumors in the
proximal tibia; and humerus (10%), with 90% of tumors in the proximal humerus. [1] Other locations
of note include the skull or jaw (8%) and pelvis (8%).
Any sarcoma that arises from bone is technically called an osteogenic sarcoma. Therefore, this
term includes fibrosarcoma, chondrosarcoma, and osteosarcoma, all named for their morphologic
characteristics. The focus of this article is osteosarcoma. Numerous variants of osteosarcoma are
known and include conventional types (ie, osteoblastic, chondroblastic, fibroblastic types) and
telangiectatic, multifocal, parosteal, and periosteal types.

PATHOPHYSIOLOGY
Osteosarcoma occurs mainly in the metaphysic of the long bones. Most tumors arise in bones
involved with the knee joint at the distal end of the femur or proximal distal end of thetibia. As a
tumor of the mesenchymal cells, osteosarcoma demonstrates production of osteiodtissue. The
tumor borders are distinct and merge into adjacent normal bone.The etiology is unknown.
Predisposing factors include, Age- (10-25), Gender-(male),Family history, Teenage growth spurt,
Tall for age, Previous treatment with radiation,Benign &non-cancerous bone tumor, Lack of
exercise, Smoking and drinking ,DNA mutation,Familial susceptibility, Injury and
Metabolic/hormonal disturbance.Once there is mutation of the DNA that activates the oncogene
which leads to adeactivation of the suppressor gene which causes a malignant osteoblast that
leads to proliferation of abnormal osteoblasts. This causes formation of osteoid tissue.The osteoid
tissue causes uncontrolled growth of the tumor in the bone and thereforecauses overcrowding of
the bone. There is then suppression of red bone marrow which leads todecreased production of
blood cells. a decrease in RBC leads to anemia while a decrease inWBC leads to a lowered
infection resistance. The overcrowding also causes pressure inside the bone which is a main
cause of pain and fractures. The cancer then metastasizes spreading toother parts of the body
especially the lungs, kidneys, CNS, liver and the spleen.