Limb salvage surgery in osteosarcoma- clinical meeting

Limb salvage surgery in osteosarcoma

1. LIMB SALVAGE SURGERY IN PROXIMAL HUMERAL OSTEOSARCOMA CLINICAL MEETING 13 th August 2013 Dr. Rajesh Arora Department of Orthopaedics UCMS & GTB HOSPITAL

2. Clinical presentation- History 28 yr old male, teacher by occupation, C/o Pain right shoulder & upper arm X one & half years. Swelling right upper arm x 3 months. pain - insidious onset - progressively increasing in intensity swelling - gradually increasing in size.

3. Patient’s history no h/o fever/deformity/weight loss/loss of appetite/night cries. no H/o trauma/ tuberculosis/ any other bone or joint pains/ neoplasia in other part of the body. Past history- not significant. Non smoker, non alcoholic. Family History- not significant.

4. Clinical examination GPE- Well nourished - average built - rest wnl . Systemic examination- wnl.

5. Local Examination Poorly defined mass on the anterolateral aspect of right upper third arm 5 cms below the acromion process. Local temperature raised Marked tenderness Consistency- firm . Non fluctuant Arising from underlying humerus. Adjoining joints normal. No DNVD / skip metastases.

6. X-ray of the right shoulder and arm AP view ill defined expansile lytic lesion in the metaphyseo -diaphyseal region with permeative pattern. No periosteal reaction No pathological fractures

7. MRI-Right whole arm with shoulder & elbow. Mildly expansile intramedullary lesion Hyperintense on T2w/STIR images, with fluid/hemorrhage levels sparing of epiphysis. Irregular periosteal reaction with cortical destruction on anterior & lateral aspect of shaft. No obvious muscle/ joint/ neurovascular bundle/joint effusion noted. S/o primary bone malignant lesion most likely Osteosarcoma ?telangiectatic variant

8. T1 T2

9. MRI-Right whole arm with shoulder & elbow.

10. Other Imaging Chest X-ray - NAD PET-CT- No e/o metastases.

11. Biopsy Trucut biopsy From anterior aspect Along expected future surgical incision. Biopsy showed fibrovascular septae lined by neoplastic osteoblastic anaplastic cells with typical & atypical mitosis. Focal areas with lacy osteoid was seen. suggestive of TELANGIECTATIC TYPE OF OSTEOSARCOMA(High grade).

12. Diagnosis Proximal humeral telengiectatic type osteosarcoma (high grade) of right(dominant) side with no associated distal neurovascular deficit OR distant/skip metastases. Stage- IIA (G2,T1,M0)

13. TREATMENT

14. As given by Tata Memorial Cancer Hospital, India.

15. STEP 1 Neo-adjuvant Chemotherapy (Induction Chemotherapy) Patient received 3 cycles of neoadjuvant chemotherapy. Had no significant chemotherapy related complications. Pain & tumour size reduced MRI also showed regression of tumour with chemotherapy Drugs given were: Ifosfamide+ Adriamycin +Cisplatin

16. Pathological fracture During 3rd cycle, patient had trivial fall f/b pathological fracture. Fracture – undisplaced t/t- POP cast immobilization (U-slab). Now ,diagnosis was: Proximal humeral telengiectatic type osteosarcoma (high grade) of right side + undisplaced pathological fracture without any distal neurovascular deficit OR distant/skip metastases.

17. STEP 2 SURGICAL MANAGEMENT Limb Salvage Vs. Limb Ablation

18. Surgical Options Have two modalities: Limb Ablation: removal of the diseased part of the limb along with the uninvolved distal extremity. Limb Salvage: removal of the diseased part of the limb and reconstruction of the defect to provide near normal functional limb.

19. Limb Ablation (amputation/disarticulation) Till 1970’s have been the mainstay of therapy for osteosarcoma. Previously was thought to provide better control of disease But has been shown by multiple studies that the survival of patient is comparable whether the limb is salvaged or amputated, provided WIDE surgical margins are obtained .

20. ADVANTAGES Though may be technically demanding , but usually doesn’t requires multiple procedures Cost efficient Doesn’t require state of art facilities Patient is least worried about damaging the affected limb Rehabilitation is easy esp. in skeletally immature patients

21. DISADVANTAGES Wound necrosis Phantom pain Bone overgrowth in children Bone protrusion Additional metabolic expenditure Gait disturbances Psychological disturbances

22. Limb salvage surgery- What is it?? Comprises of operations to save the limb rather than amputate. Goal- To preserve a useful functioning limb without increasing the risk to the patient

23. Advantages Higher walking velocity Higher maximal aerobic capacity. Better function. Better gait Less psychosocial consequences. No stump related complications.

24. Disadvantages Limited availability of facilities Expensive Long & emotionally complex rehabilitation Infections Delayed/nonunion Joint instability Late OA Endoprosthetic loosening/dislocation Need of revision/multiple surgeries Deep venous thrombosis Periprosthetic or allograft fracture.

25. Contraindications/ Barriers Patient not willing. Limited financial resources. Lack of facilities/ surgical skills Pathological fracture with hematoma violating compartment boundary Encasement of major vessel when vascular bypass not feasible Encasement of major motor nerve

26. Contraindications/Barriers Poorly placed biopsy incisions or biopsy site complications Severe infection in the surgical field Extensive muscle or soft tissue involvement Poor response to neo-adjuvant chemotherapy Immature skeletal age with predicted limb length discrepancy > 8 cms.

27. Principle of LIMB SALVAGE Optimal Resection of the tumour + Reconstruction of the resulting surgical defect in the limb to provide near normal function

28. What are ‘ ADEQUATE MARGINS ’?? Adequate margins are one that results in an acceptably low rate of local recurrence of the tumour For high grade sarcomas wide margins are ‘adequate’ Successful control of primary tumour in 95% cases

29. TECHNIQUES OF RECONSTRUCTION Depends upon the type of defect after resection

30. Joint involving defects Two options Arthroplasty OR Arthrodesis

31. Megaprosthesis A large metallic joint designed to replace the excised length of bone & the adjacent joint. fully constrained hinge joints. Previously custom made, reqd. 4 -6 wks. Nowadays , modular option available providing intraoperative flexibility. decreased cost. reducing delay.

32. Megaprosthesis Advantages Provide immediate return to function Not affected by ongoing adjuvant therapy like chemo-/radiotherapy Better functional results as compared to amputation+ external prosthesis Disadvantages Implant loosening Excessive wear High cost Infection Local recurrence Periprosthetic fracture Limb length discrepancy if used in skeletally immature patients

33. RECONSTRUCTION USING OSTEOARTICULAR ALLOGRAFT Allograft with the articular surfaces have been used to bridge large bone defects with success rate of 72%. Advantages : provides a biological bed for soft tissue attachment, attachment of muscle insertions makes function with allograft better than that with prosthesis. Disadvantages : It has poor revascularization rate & acts like a biological spacer Complications like infection (5-15%), fracture (15-20%), non-union(15-20%) and OA due to collapse of articular surface. Chemotherapy & radiotherapy delays union Potential for transmission of bacterial/viral disease Needs presence of bone banks with ample samples of graft.

34. ALLOPROSTHESIS COMPOSITE

35. Reconstruction by Arthrodesis Usually obtained by bone allografts, vascularized autograft or both using K- nail, IM nail, or plates.

36. So, What to do??

37. Issues which we considered before planning the surgery Survival of the patient. Short term and long term morbidity associated. Function of the salvaged limb vs. with that of prosthesis. Psychosocial consequences of the procedure.

38. Patient & patient’s family education Essential for decision making process. Detailed counseling about: Costs involved Change in lifestyle and mobility Risks & possible complications Possibility of intra-operative change of plan of surgery to amputation. Possibility of additional procedures in future.

39. How much of humerus should be resected??

40. Resection of the tumour Using extended deltopectoral approach an intra-articular resection of the 21 cm. of humerus (from shoulder joint) including the tumour was done. The margins of excision were kept ‘wide’. Excluding posterior most fibers of deltoid, the whole of the deltoid and axillary nerve were sacrificed. Brachialis muscle which was attached to anterior surface of humerus was partially excised. All other neurovascular structures were carefully dissected and protected .

41. RESECTED TUMOUR WITH HUMERAL HEAD Humeral head Nearly whole of deltoid excised with the tumour All muscles attached to the excised humerus were cut approx 1-2 cm away from the bone to provide wide margin of resection

42. RESECTED TUMOUR WITH HUMERAL HEAD Skin at & near biopsy scar excised Nearly whole of deltoid excised with the tumour Humeral head

43. RESECTED TUMOUR WITH HUMERAL HEAD Blood filed cysts s/o telangiectatic variant Distal extent of the tumour Intramedullary Tissue from distal tip of the humerus was sent for frozen section

44. MARGINS- FROZEN SECTION Margins sent for frozen section evaluation. Found to be tumour free indicating adequate margins. (HPE No. 8720/13)

45. Reconstruction using Megaprosthesis Titanium based modular megaprosthesis was used. Fixed to the distal humerus using bone cement (PMMA). Implant make – Adler co. in collaboration with Tata Memorial Cancer Hospital, Mumbai.

46. Use of Prolene Mesh A prolene mesh was rolled like a cylinder. At the distal end of the mesh, a purse string suture was applied.

47. Use of Prolene Mesh upper end of the cylinder was sutured to the glenoid labrum. scaffold for fibrosis around the megaprosthesis act like a checkrein & help in maintaining the prosthesis in glenoid provide anchor for various muscle attachments.

48. Prosthesis fixed to distal humerus using bone cement Radial nerve protected from thermal injury as the cement sets Prosthesis secured in the glenoid

49. Wound Closure

50. Wound Closure

51. Summary of the surgery Wide resection of tumour (excision of 21 cm of proximal humerus) with excision of deltoid muscle & axillary nerve + Reconstruction of bony defect using cemented modular titanium megaprosthesis. Total blood loss -1800 ml. Postoperative course- Uneventful No DNVD except loss of sensation in regiment batch area. Total blood transfusion received- 3 units WB.

52. Post-op X-ray

53. Post operative rehabilitation The operated limb has been immobilized by POP U-slab and broad arm sling x 3 weeks Skin sutures to be removed on 14 th post-op day. Wound healthy & healing at normal pace

54. STEP 3 Multi-agent adjuvant chemotherapy Will be started after suture removal approx. 2 weeks Treat micro metastasis post-operatively Combination regimes combat drug resistance Regimen to be used-percent of necrosis < 90% poor response to neoadjuvant > 90% good response to neoadjuvant

55. MODERN MANAGEMENT OF OSTEOSARCOMA- Conclusion SURGERY+ CHEMOTHERAPY- mainstay of management. Surgical mgmt. of osteosarcoma is challenging Advancement in imaging, biomechanical engineering, surgical techniques & availability of low cost & effective chemotherapeutic agents Limb salvage surgery -standard care for osteosarcoma (successful in 85%) Should be the aim but not at the cost of patient survival.

56. OSTEOSARCOMA Most common non-hematological primary malignant tumor of the bone. Characterized by production of osteoid by malignant cells. Can occur at any age, mc 2 nd decade Slightly more common in males.

57. OSTEOSARCOMA Location- usually areas of most rapid bone growth including distal femur(m.c.), proximal tibia & proximal humerus Usually metaphyseal,10% diaphyseal,<1% epiphyseal. Metastasis by blood stream Lymphatic spread- rarely Lungs most common site of mets.

58. Primary Osteosarcoma Conventional intramedullary (75-85%,most common) Low grade intramedullary Periosteal Paraosteal High grade surface osteosarcoma (least common) Telengiectatic Small cell osteosarcoma Classification of Osteosarcoma

59. Classification of Osteosarcoma Secondary Osteosarcoma at site of another disease process; usually>50 yrs Paget’s disease associated (1 % incidence, 6 th -8 th decade) Radiation associated (1% incidence, >2500 cGy exposure, m.c. radiation assoc. sarcoma)

60. Prognostic factors Tumour stage (most imp.) Pulmonary metastases- bad prognosis Non-pulmonary- worse prognosis (like bone metastases/skip lesions) Grade (high grade-worse prognosis) Size of the primary tumour Location (proximal location-worse prognosis) Secondary osteosarcoma- poorer prognosis Age & Gender- no prognostic significance

61. Telangiectatic osteosarcoma aggressive variant; high grade (5%) pathological fractures more common. Grossly, a blood filled cyst with limited solid portion often entirely osteolytic on plain x-ray. Can have an invasive appearance or ballooned appearance like aneursymal bone cyst. Similar treatment & prognosis to conventional osteosarcoma.