Osteosarcoma Case

Osteo – comes from the ancient Greek word for bone, sarcoma – is the name given to cancer. Osteosarcoma is the most common type of primary bone cancer. It starts when bone cells become abnormal, growing out of control to form a lump of cancerous tissue. The cancerous tissue consists of abnormal cells that are attempting to make bone. Being able to see this abnormal bone under a microscope helps to confirm a diagnosis of osteosarcoma. The cause really is unknown but genetics can play a role. The majority of osteosarcoma arises from a single place within the area of a long bone known as the methaphysis, which contains the growing areas of the bone called the epiphyseal plate. The site at which the cancer starts is known as the primary tumor site. A long bone is much longer than it is wide. The best examples being the bones of the limbs: the femur and the humerus.

The three areas most often affected by osteosarcoma are the lower thigh bone nearest to the knee the distal femur 48%, the upper bone nearest to the knee the proximal tibia 27% and the upper arm bone nearest to the shoulder the proximal humerus 15%. Other bones can be affected such as the jaw, the spine, and the pelvis 6%. Tumors found in the bones of the face, skulls and spine are more common in older patients. Osteosarcoma usually behaves in an aggressive manner, which means it can spread in the bloodstream from or though the bone in which it starts to other places in the body.

The most common place for it to spread is the lungs. Osteosarcoma can also spread to other places in the body including other bones. That is because osteosarcoma spreads at a early stage, as well as the treatment to the site of the primary tumor, patients needs treatment to the whole body, this is called a systemic treatment. This cancer can affect people of all ages, but is mostly found in older children, teenagers and young adults between the ages of 10 to 24 it affects 75% of this population. This type of cancer affect males slightly, females are mostly common affected approximately 1.4 times more females are affected than males it tends to occur at an earlier age in girls than in boys. That may be because girls have a growth spurt at an earlier age. About 400-1000 new cases are diagnosed per year in the United States.

The most common symptoms that people report and clinical signs are: bone pain, may be intermittent at first then becoming more persistent, especially at night. Swelling, this can be seen if it is on a bone near the surface of the body, but in other places like on the pelvis, it may not be visible. Last but not least, reduced movement on a joint, or a limp. If you have symptoms you might want to go to the doctor “General Practitioner”. He might tell you do to some exams such as: x-rays, blood test, MRI Scan, CT Scan, Bone Scan, PET Scan. He might as well refer you to a Bone Cancer Center or a specialist to perform a biopsy. After performing the entire tests and going to the doctors you might want to go to a Regional Cancer Center for more tests and to start treatment. When you start treatment you need to now three things: How aggressive the tumor is? Low grade: slow growing or high grade: fast growing, How extensive is the cancer? And has the cancer spread? When you decide and feel ready for treatment there are many options.

Options for Treatment:
A. Surgery and Chemotherapy “Systemic Treatment”
B. Chemotherapy then Surgery
C. Surgery, Chemotherapy and Radiation
D. Chemotherapy, Surgery and Non-adjutant (rare type of chemotherapy)

Examples of protocols of chemotherapy are:
The mix of Dexorubicin, Methotrexate, Cisplatin and Ifosfamide or the mix of Carboplatin, Epiribicin, Etoposide and Cytoxan. The combination of medicine depends on the patient weight, the height, the heart function and the age.

Examples of Surgery:
1. Intralesional – curettage, partial tumor removal.
2. Marginal – margin is reactive zone, may leave microscopic tumor behind.
3. Wide – remove tumor and surrounding cuff of normal tissue. 4. Radical – remove entire compartment, includes amputation.

The radiotherapy when used is only in the part of the bone that is affected, this treatment its daily as long as 12 to 40 days. May also used to treat more advanced cancers when surgery may not be as effective or to shrink tumors and relieve symptoms if the cancer has spread.

How to combat the most common pain of osteosarcoma?
• Heat or cold compresses to the area
• Relaxation techniques to help handle pain
• Massage the area that hurts, you can go to a professional for the massages.
• Oral, IM or patch medication such as: Morphine, Demerol, Valium, Toradol, Oxicontin
• In some cases the doctor might recommend nerve block to handle the pain.

The 80% of the patients diagnosed with osteosarcoma have micrometastatic disease. This is the reason that the systemic chemotherapy is used but if the tumor has not spread to the lungs long term survival rates are better. Survival rates are often used by doctors as a standard way of discussing the prognosis of a person with certain type and stage of cancer. Some patients or parents of small patients may want to know the survival statistics for people in a similar situation, while others may not find the numbers helpful, or may even not want to know them. The 5 years survival rates refers to the percentage of patients who lives at least 5 years after their cancer is diagnosed. Of course many people live much longer than 5 years and many are cured.

Factors that may affect the prognosis:
+ Younger Age (child or young adult, as opposed to older adult)
+ Female Gender
+ Tumor is located on an arm or leg (as opposed to the hip bones)
+ Tumor can be resected
+ Normal blood alkaline phosphatase and LDH levels
+ Good tumor response to chemotherapy

What’s new in Osteosarcoma?
Around the world, there are many studies been done about osteosarcoma. At this time the studies are making progress, they are studying more information about the DNA changes that cause this cancer. They will eventually result in the development of specific treatment to correct the changes in the DNA. A test of gene changes called gene expression profiling may help predict the behavior of each tumor, such as how to respond to certain types of chemotherapy.

What’s new in osteosarcoma surgery?
Doctors have a much better understanding of the typical growth and spread of osteosarcoma than they did in the past. This along with new imaging test that best define the extent of tumors. This lets the doctor plan surgeries that remove the cancer while sparing as much normal tissue as possible. Some new types of internal prosthesis can now be expanded without the need for more surgery. This is especially important for children, who in the past often needed several operations to replace the prosthesis with a larger one as they grew.

What’s new in osteosarcoma chemotherapy?
There are many clinical trials to determine the best combinations of chemotherapy drugs. The lungs are the most common place for osteosarcoma to spread inhaled forms of some chemotherapy drugs such as cisplatin, are being studied for patients whose cancer has spread to their lungs. Early results have positive change.

Doctors now are studying others medicine NO chemotherapy to help patient with osteosarcoma. Examples:
1. Inmune- modulation drug called “muramyl tripeptide” has been shown to help some patient when added to chemotherapy. 2. Target medicine using to attack molecular proteins that are called “monocional antibodies”. 3. Other target medicine is the osteoclast for example is the bisphosphonates “this drug is used for osteoporis”. Other medicine in the same line is Zeledonic Acid. 4. Other new drugs being studied are bevacizumab, cediranib and sorafenib (they are chemo) 5. Other new drugs that are being tested are torisel and afinitor.

To conclude, osteosarcoma is not a common disease or a common type of cancer. If the cancer is diagnosed in an early stage patients can have a better prognosis. This cancer commonly attacks children and young adults if the cancer is diagnose in an early stage and treated aggressively the patient can have a longer and better life after combating the cancer. At this moment, osteosarcoma has no cure but there are many studies that are showing good results for future treatment as well for giving patients a better quality of life.

Bibliography

American Cancer Society
http://www.cancer.org/

The Liddy Shriver Sarcoma Initiative
http://sarcomahelp.org/

St. Jude Children’s Research Hospital
http://www.stjude.org/stjude/v/index.jsp?vgnextoid=f87d4c2a71fca210VgnVCM1000001e0215acRCRD

National Cancer Institute
http://www.cancer.gov/

The Bone and Cancer Foundation
http://www.boneandcancerfoundation.org/