OSTEOSARCOMA RIGHT FEMUR

Presented:
Adi Imam Setiawan C111 12 108
Andi Raynaldi C111 11 900
Nety Nur Rahmiah Puspitasari C111 11 270
Rahmaniah Kadir C111 12 252

Resident:
dr. Qariah Maulidiah
dr. Khrisna Yudha

Supervisor:
dr. Dewi Kurniati Paturusi,M.Kes. Sp.OT

Oktober 2017th
Orthopaedic and Traumatology Department
Faculty of Medicine Hasanuddin University
CASE REPORT
 PATIENT IDENTITY

PATIENTEN
PATIENT IDENTITY
IDENTITY
Name : Mr. MI
HISTORY TAKING

PHYSICAL Age : 18 years old / Male

EXAMINATION

CLINICAL FINDING
Admissionx : October 1th, 2017 at 16.30 WITA
INVESTIGATION

RESUME Registration : 815991

ASSESMENT

THERAPY
 HISTORY TAKING
Chief complaint : lump at right thigh
PATIENT IDENTITY
Patient came on 1 October 2017 to the ER of Wahidin
Hospital with a chief complain of pain in right thigh lump.
HISTORY TAKING
Complaints are felt by patients since 5 months ago. Initially
PHYSICAL
EXAMINATION the patient struck the banner scroll on the right thigh. After
that the patient felt the pain and was taken to the bone setter,
CLINICAL FINDING because he didnt recover, the next day the patient went to the
hospital and declared his bone cracked from radiological.
INVESTIGATION The pain is felt on the whole right foot, especially in the
RESUME proximal femur, the pain disappears, and incidence usually at
night with cold sweat, no fever In the patient was installed
ASSESMENT splint and medical treatment. 2 months after that the patient
is healed and can walk. One day when the patient wants to
THERAPY
stand up from a squatting position, the patient feels a crack
from his right thigh and the patient cant stand after that the
patient's thigh begins to swell as big as a soccer ball.
 HISTORY TAKING
The patient went back to the doctor and performed a biopsy
PATIENT IDENTITY examination with histopathological examination: distal dextra
femur: osteosarcoma, invasion of tissue and muscle. and the
HISTORY TAKING patient is advised for amputation, but the patient refuses. The
PHYSICAL patient was referred from papua to Wahidin Hospital. weight loss
EXAMINATION us much 15 kg in 2 months.
CLINICAL FINDING

INVESTIGATION

RESUME

ASSESMENT

THERAPY
 HISTORY TAKING

PATIENT IDENTITY History of Past Illness

HISTORY TAKING No history of falls, no hypertension, no

PHYSICAL
EXAMINATION diabetes mellitus, history with the same

CLINICAL FINDING
complaint previously denied.
INVESTIGATION

RESUME
History of Family

ASSESMENT
The same history of disease in the family is
THERAPY
denied
 GENERAL STATUS

PATIENT IDENTITY Awareness : Compos mentis

Blood Pressure : 110/80 mmHg
HISTORY TAKING
Respiratory : 22 x / min
PHYSICAL Heart Rate : 83 x / min
EXAMINATION
Temperature : 36.8C
CLINICAL FINDING
Pupil: isokor, 2.5 mm / 2.5 mm, light reflex + / +
INVESTIGATION
Head: Palpebral conjunctiva (- / -), jaundice sclera (- / -)
RESUME Extremitas Inferior : Warm (+), Enlargement of inguinal
ASSESMENT dextra lymph nodes
THERAPY
 CLINICAL FINDING

PATIENT IDENTITY

HISTORY TAKING

PHYSICAL
EXAMINATION

CLINICAL FINDING

INVESTIGATION

RESUME

ASSESMENT

THERAPY

Anterior Aspect
 CLINICAL FINDING

PATIENT IDENTITY

HISTORY TAKING

PHYSICAL
EXAMINATION

CLINICAL FINDING Medial Aspect

INVESTIGATION

RESUME

ASSESMENT

THERAPY

Lateral Aspect
 CLINICAL FINDING
Site of Biopsy
PATIENT IDENTITY (29 08 2017)

HISTORY TAKING

PHYSICAL
EXAMINATION

CLINICAL FINDING

INVESTIGATION

RESUME

ASSESMENT

THERAPY
histopathological examination: distal dextra femur: osteosarcoma, invasion
of tissue and muscle
 LOCAL STATUS
Right Thigh Region:
PATIENT IDENTITY
Look : Lump as big as soccer ball , with color same as the
sorrounding skin, there is venektasi, there is a wound on the lateral
HISTORY TAKING
thigh size 5 x 1 cm
PHYSICAL
EXAMINATION Feel : lump with size 18 x 30 x 14 cm the largest diameter 56
cm, consistency is hard (+) with smooth surface, immobile ,
CLINICAL FINDING
tenderness (+), enlargement of inguinal glands size 2 cm. Bruit (+).
INVESTIGATION
Move : Active and passive movement of the hip joint can not be
RESUME assessed because of pain. Active and passive movement of the knee
joints can not be assessed because of pain
ASSESMENT

THERAPY NVD : Sensibility are good, Pulsation: Posterior tibialis artery

and dorsalis pedis artery are palpable adequate, Capillary refill time
: 2 seconds
 Radiological Finding
RADIOLOGICAL FINDING
Pelvis AP
PATIENT IDENTITY

HISTORY TAKING

PHYSICAL
EXAMINATION

CLINICAL FINDING

INVESTIGATION

RESUME

ASSESMENT

THERAPY
 Radiological Finding
RADIOLOGICAL FINDING
Femur Dextra

PATIENT IDENTITY

HISTORY TAKING

PHYSICAL
EXAMINATION

CLINICAL FINDING

INVESTIGATION

RESUME

ASSESMENT

THERAPY
 Radiological Finding
RADIOLOGICAL FINDING
Thorax AP
PATIENT IDENTITY

HISTORY TAKING

PHYSICAL
EXAMINATION

CLINICAL FINDING

INVESTIGATION

RESUME

ASSESMENT

THERAPY
 Radiological Finding
RADIOLOGICAL FINDING
Thorax Lateral
PATIENT IDENTITY

HISTORY TAKING

PHYSICAL
EXAMINATION

CLINICAL FINDING

INVESTIGATION

RESUME

ASSESMENT

THERAPY
 LABORATORY FINDING

PATIENT IDENTITY Component Result Reference Value

HB 9.4 12,00-16,00 gr/dl
HISTORY TAKING
WBC 8,06 4,00-10,00 . 10^3/ul
PHYSICAL HCT 31.0 37,0 48,0 %
EXAMINATION
PLT 300 140-400 . 10^3/ul
CLINICAL FINDING
CT 8 4-10 menit
INVESTIGATION BT 3 1-7 menit
RESUME SGOT 47 <38 U/L

ASSESMENT SGPT 15 <41 U/L

Albumin 3,7 3,5-5,0 gr/dl
THERAPY
LDH 689 210-425 U/L
 RESUME
PATIENT IDENTITY Male, 18th years old, to the ER of Wahidin Hospital with a
chief complain of pain in right thigh bumps since 5 months ago.
HISTORY TAKING
Initially the patient struck the banner scroll on the right thigh.
PHYSICAL After that the patient felt the pain and was taken to the bone
EXAMINATION
setter, because he didnt recover the next day the patient went to
CLINICAL FINDING
the hospital and declared his bone cracked from radiological. the
INVESTIGATION pain is felt on the whole right foot, especially in the proximal
RESUME femur, the pain disappears, and incidence usually at night with
ASSESMENT cold sweat, no fever. In the patient was installed splint and

THERAPY medical treatment. 2 months after that the patient is healed and
can walk. One day when the patient wants to stand up from a
squatting position,
 RESUME

PATIENT IDENTITY the patient feels a crack from his right thigh and the patient
cant stand after that the patient's thigh begins to swell as
HISTORY TAKING
big as a soccer ball. The patient went back to the doctor
PHYSICAL and performed a biopsy examination with
EXAMINATION
histopathological examination: distal dextra femur:
CLINICAL FINDING osteosarcoma, invasion of tissue and muscle. and the
INVESTIGATION patient is advised for amputation, but the patient refuses.
RESUME The patient was referred from papua to Wahidin Hospital.
Weight loss us much 15 kg in 2 months. History of Past
ASSESMENT
Illness ,no history of falls, no hypertension, no diabetes
THERAPY
mellitus, history with the same complaint previously
denied. None of his family member suffered from such
illness.
 RESUME
From physical examination, general status within normal limits.
PATIENT IDENTITY
There is swelling in right thigh bumps. Look, Lump as big as soccer
ball , with color same as the sorrounding skin, there is venektasi,
HISTORY TAKING there is a wound on the lateral thigh size 5 x 1 cm. Feel, lump with
size 18 x 30 x 14 cm the largest diameter 56 cm, consistency is
PHYSICAL hard (+) with smooth surface, immobile , tenderness (+),
EXAMINATION enlargement of inguinal glands size 2 cm. Bruit (+). Move :Active
and passive movement of the knee joints can not be assessed
CLINICAL FINDING
because of pain. NVD, Sensibility are good, Pulsation: Posterior
INVESTIGATION tibialis artery and dorsalis pedis artery are palpable adequate,
Capillary refill time : 2 seconds. From radiology finding, Pelvic
RESUME AP : Multiple lytic lesions on the head to the trochanter minor os
femur dextra. From femur dextra : An osteosarcoma os femur dextra
ASSESMENT
and multiple lytic lessions on the caput to the minor trochanter os
THERAPY femur dextra. Cruris dextra : an osteosarcoma os femur dextra and
multiple proximal lytic lession to the middle of the tibia dextra os.
 ASSESSMENT

PATIENT IDENTITY

HISTORY TAKING

PHYSICAL
EXAMINATION

CLINICAL FINDING

INVESTIGATION

RESUME

ASSESMENT

THERAPY
 THERAPY

PATIENT IDENTITY IVFD Ringer Lactate

HISTORY TAKING
Analgetic
PHYSICAL Plan for Disarticulation
EXAMINATION
Blood Tranfusion PRC 2 Bag
CLINICAL FINDING

INVESTIGATION

RESUME

ASSESMENT

THERAPY
 DISCUSSION
OSTESARCOMA
 INTRODUCTION
Osteosarcoma, the most common bone sarcoma, is
characterized by production of both tumor osteoid
and immature bone matrix.

The most common site of metastases (80% to 85%) is

the lungs.

Metastases to bone is the second most common

course.

Messerschmitt PJ, Garcia RM, Abdul-Karim FW et al. Review Article: Osteosarcoma; J Am Acad Orthop Surg 2009; 17: 515-527
Malawer M.M, Sugarbaker P.H. Musculoskeletal Cancer Surgery: Treatment of Sarcomas and Allied Disease.Washington Cancer Instit
 INTRODUCTION
Incidence of osteosarcoma peaks in the second
decade of life during periods of rapid bone
turnover, such as the adolescent growth spurt.

Distal femur (35%)

Proximal tibia (20%)

PREDILECTION SITES

Messerschmitt PJ, Garcia RM, Abdul-Karim FW et al. Review Article: Osteosarcoma; J Am Acad Orthop Surg 2009; 17: 515-527

Banaszkiewics PA, Kader DF, Maffulli N. Postgraduate Orthopaedics:The Candidates Guide To The FRCS (Tr & Orh) Examination;2009.
 More than 85% of osteosarcoma cases
are categorized as primary
osteosarcoma
Conventional

Small-cell
INTRAMEDULLAR
Y SUBTYPES Low-grade
intramedullary

OSTEOSARCOM Telangiectatic
A
Parosteal

SURFACE
Periosteal
SUBTYPES
High-grade surface

Messerschmitt PJ, Garcia RM, Abdul-Karim FW et al. Review Article: Osteosarcoma; J Am Acad Orthop Surg 2009; 17: 515-527
 ETIOLOGY

Rarely inherited.

70% of osteosarcoma tumor specimens demonstrate a

chromosomal abnormality.

Genetic predisposition commonly involves mutations in

tumor-suppressor genes or in DNA helicases.

Messerschmitt PJ, Garcia RM, Abdul-Karim FW et al. Review Article: Osteosarcoma; J Am Acad Orthop Surg 2009; 17: 515-527
Malawer M.M, Sugarbaker P.H. Musculoskeletal Cancer Surgery: Treatment of Sarcomas and Allied Disease.Washington Cancer Institut
 CLINICAL PRESENTATION

Swelling & soft-tissue oedema.

Bony enlargement and soft-tissue extension.

Pain, typically worse at night (often mistaken for growing pains).

Cachexia and weight loss.

Coincidental injury.

Pathological fracture through lesion (510%)

Rarely, symptoms of metastasis to lung (shortness of breath, chest pain, haemoptysis).

Neuralgia or paraesthesia from nerve compression.

Malawer M.M, Sugarbaker P.H. Musculoskeletal Cancer Surgery: Treatment of Sarcomas and Allied Disease.Washington Cancer Institut
Banaszkiewics PA, Kader DF, Maffulli N. Postgraduate Orthopaedics:The Candidates Guide To The FRCS (Tr & Orh) Examination;2009.
 PHYSICAL EXAMINATION
Location
Skin color (hyperemia)
Ulcers (+/-)
Shiny skin
LOOK Venectasis
Muscle atrophy
Distal edema
Size
FEEL
Warmth
Consistency MOVE
Mobility
Border
Active &
Tenderness
passive ROM
Lymph Auscultate for bruits
nodes
Messerschmitt PJ, Garcia RM, Abdul-Karim FW et al. Review Article: Osteosarcoma; J Am Acad Orthop Surg 2009; 17: 515-527
CLINICAL FINDING
 IMAGING

Plain
radiographs CT scan

Bone
MRI
scintigraphy

Hide, Geoff. 2011. Imaging In Clasic Osteosarcoma

 IMAGING

Radiographs classically demonstrate

an aggressive bone lesion arising from
the metaphysis of the distal femur,
proximal tibia, or proximal humerus.

The lesion typically has defined

borders, osteoblastic and/or osteolytic
features, and an associated soft-tissue
mass.

Messerschmitt PJ, Garcia RM, Abdul-Karim FW et al. Review Article: Osteosarcoma; J Am Acad Orthop Surg 2009; 17: 515-527
 SYSTEMATIC PLAIN X-RAY READING

Zone of transition (narrow or

wide)

Periosteal Reaction
(Codmans triangle, sunburst
appearance)

Matrix (osteoid,
chondrogenic, fibrogenic)

Soft tissue swelling

 SYSTEMATIC PLAIN X-RAY READING

Location (metaphysis, epiphysis, diaphysis)

 STAGING

Staging is the process of classifying a tumor, especially a malignant tumor,

with respect to its degree of differentiation, as well its local and distant
extent, in order to plan the treatment and estimate the prognosis.

Staging of a musculoskeletal tumor is based on:

Biopsy &
Physical Imaging histopatholo
examination studies gy

Messerschmitt PJ, Garcia RM, Abdul-Karim FW et al. Review Article: Osteosarcoma; J Am Acad Orthop Surg 2009; 17: 515-527
Malawer M.M, Sugarbaker P.H. Musculoskeletal Cancer Surgery: Treatment of Sarcomas and Allied Disease.Washington Cancer Institut
 AJCC STAGING SYSTEM

Banaszkiewics PA, Kader DF, Maffulli N. Postgraduate Orthopaedics:The Candidates Guide To The FRCS (Tr & Orh) Examination;2009.
 Stage on a Malignant Tumor
The Enneking system for staging malignant bone tumors,
including osteosarcoma, is the most recognized method.

Stage I
Low degree of malignancy
IA: Intracompartment
IB: Extracompartment

Stage II

High degree of malignancy

IIA: Intracompartment
IIB: Extracompartment

Stage III
Tumor has already metastase
 LABORATORY TESTS

Baseline laboratory values should be obtained to assess organ

function before the initiation of preoperative chemotherapy.

Alkaline phosphatase osteoblastic activities.

Lactate dehydrogenase osteoclastic activities.

Messerschmitt PJ, Garcia RM, Abdul-Karim FW et al. Review Article: Osteosarcoma; J Am Acad Orthop Surg 2009; 17: 515-527
 TREATMENT

Operative (excision teh tumour)

Radiotherapy

Multi- agent chemotherapy

Amputation
 TYPES OF EXCISION
ENNEKING

Messerschmitt PJ, Garcia RM, Abdul-Karim FW et al. Review Article: Osteosarcoma; J Am Acad Orthop Surg 2009; 17: 515-527
Malawer M.M, Sugarbaker P.H. Musculoskeletal Cancer Surgery: Treatment of Sarcomas and Allied Disease.Washington Cancer Institut
 PROGNOSIS

Cumulative 5-year
survival is 58% for men
and 59% for women for all
types of primary bone
sarcoma combined.

Banaszkiewics PA, Kader DF, Maffulli N. Postgraduate Orthopaedics:The Candidates Guide To The FRCS (Tr & Orh) Examination;2009.
Malawer M.M, Sugarbaker P.H. Musculoskeletal Cancer Surgery: Treatment of Sarcomas and Allied Disease.Washington Cancer Institut
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