1 ELBOW RECONSTRUCTION FOR DISTAL HUMERUS OSTEOSARCOMA BY USING EXTRACORPOREAL IRRADIATION AUTOGRAFT ( TWO CASE REPORTS ) Yanuarso, A Fauzi K, Errol Untung Hutagalung Division of Orthopaedic and Traumatology Faculty of Medicine University of Indonesia • Malignant bone tumors are rare lesions : • Malignant bone tumors are rare lesions : – RSCM →1,3% of all the cancer load (Errol UH, unpublished data, 2006) – Mayo Clinic → 1-2% • Osteosarcoma → the 2 nd common • Osteosarcoma → the 2 nd common malignant bone tumors after multiple myeloma Æ19% Dahlin’s bone tumors general aspects and data on 11,087 cases.1996. pp.143 Dahlin’s bone tumors general aspects and data on 11,087 cases.1996. pp.143-95 95
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Elbow Reconstruction for Distal Humerus Osteosarcoma
Elbow Reconstruction for Distal Humerus Osteosarcoma
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ELBOW RECONSTRUCTION FOR DISTAL HUMERUS OSTEOSARCOMA
BY USING EXTRACORPOREAL IRRADIATION AUTOGRAFT
( TWO CASE REPORTS )
Yanuarso, A Fauzi K, Errol Untung Hutagalung
Division of Orthopaedic and TraumatologyFaculty of Medicine
University of Indonesia
• Malignant bone tumors are rare lesions :• 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(Errol UH, unpublished data, 2006) – Mayo Clinic → 1-2%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• 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.143Dahlin’s bone tumors general aspects and data on 11,087 cases.1996. pp.143--9595
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• 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 g pmalignant tumor and reconstruction of the limb with an acceptable oncologic, functional, and cosmetic result
JJ Am Acad Orthop Surg 2003;11:25Am Acad Orthop Surg 2003;11:25--37.37.
FIRST CASEA girl, 22 yo• History of a lump in the left distal humerus
that was getting bigger since 6 months ago • The pain and loss of function were present• There was no trauma
Left elbow AP and lateral X-ray (January 2006) :- Blastic and lytic lesions in the left distal humerus- Periosteal reaction and soft tissue swelling
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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
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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
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Clinico Pathological Conference (CPC)• Diagnosed as conventional osteosarcoma
neoadjuvant chemotherapy
• Planned for limb salvage surgery using an extracorporeal irradiation of distal humerusextracorporeal irradiation of distal humerus
Limb Salvage SurgeryFirst 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 &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
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Second Stage :• Reconstruction of the half
distal humerus with plate and screwscrew
• 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 tumorSo 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
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SECOND CASEWoman, 30 yo • History of recurrent lump at left distal humerus
th t tti bi i 2that was getting bigger since 2 years ago
9 years ago(1997)
• a lump arised at
2 years ago (April 2004)
• tumor was
4 months b.a
• after firsta lump arised at posterior distal portion of left shaft humerus
tumor was excised
after first operation a lump arised again at the same site
Local Status :Mass :• 32 cm in circumferential
length (23 cm in the health tissue)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)
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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
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Review slide from first operation :Spindle cells, minimal cytologic atypia and rare mitotic figure, osteoid positif
Clinico Pathological Conference (CPC)Di d t t l• Diagnosed as reccurrent parosteal osteosarcoma
• Planned to limb salvage procedure using extra corporeal irradiation
fautograft • Death : Nov 2007
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Limb Salvage Surgery
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 yproximal shaft with plate and screw
• Olecranon was fixed with the tension band wire
• Common flexor and extensor origins were sutered again to thesutered again to the original sites
• Radiohumeral joint was fixed with the K wire for temporary
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Post-operative X rays :Humeral shaft fixed with plate and screw and olecranon fixed with TBW
• Primary malignant bone tumors → rare lesions
• Before 1970s → routine management was consisted of transbone amputations or disarticulationdisarticulation → dismal survival rate 10-20%
Dahlin’s bone tumors general aspects and data on 11,087 cases.1996. pp.143Dahlin’s bone tumors general aspects and data on 11,087 cases.1996. pp.143--95.95.
JJ Am Acad Orthop Surg 2003;11:25Am Acad Orthop Surg 2003;11:25--37.37.
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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
JJ Am Acad Orthop Surg 2003;11:25Am Acad Orthop Surg 2003;11:25--37.37.
Consideration of Limb Salvage Procedure :
1. An upper extremity tumor → needs resection of the articular portion of theresection 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]J Bone Joint Surg [Br] 1996;781996;78--B:652B:652--57.57.
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First Stage :R ti f th h lf di t l
Second Stage :R t ti f th
Limb Salvage Surgery
• Resection of the half distal humerus that contain tumor
• Osteotomy of olecranon,• Conservation of nervus &
muscle groups, except the muscle attached to the tumor
• Reconstruction of the half distal humerus with plate & screw
• Fixation of the olecranon with TBW
• Sutured the common flexor and extensor origins to the originaltumor.
• The resected humerus sent to BATAN for irradiation with dose 30,000 rads
origins to the original sites
• Radiohumeral joint was fixed with the K wire for temporary
Result
II. Parosteal osteosarcoma
1. Limb salvage surgery
I. Conventional osteosarcoma
1 N dj t 1. Limb salvage surgery directly
2. No chemotherapy before
Result : ROM of elbow joint 30-90°
Follow-up :
1. Neoadjuvant chemotherapy
2. Limb salvage surgery3. Evaluation of neoadjuvant
chemotherapy agents revealed to unresponder group (HUVOS I) change to another chemotherapy agents Follow up :
Elbow joint functiong
Result in 1st mo :ROM of elbow joint 35-75°
Follow-up :Elbow joint function
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• The management of malignant boneThe 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• Functional outcome and patient satisfaction appear to be at least as good, and probably better after reconstruction than after ablation