OSTEOSARCOMA

OSTEOSARCOMA

Definition• Osteosarcoma is a cancerous (malignant) bone

tumor that usually develops during the period of rapid growth that occurs in adolescence, as a teenager matures into an adult.

Causes

• The exact cause is unknown

Risk factors• Age

– The risk of osteosarcoma is highest during the teenage "growth spurt

– The risk goes down in young adults, but rises again in older adults (usually over the age of 60).

• Height– Patients are usually tall for their age. This is

another indication that osteosarcoma may be related to rapid bone growth.

• Gender– More common in males than in females.– Females tend to develop it at a slightly earlier age,

possibly because they tend to have their growth spurts earlier.

Risk factors• Race/ethnicity

– Osteosarcoma is slightly more common in African Americans than in whites.

• Radiation to bones– People who were treated with radiation therapy for

another cancer may have a higher risk of later developing osteosarcoma

• Certain bone diseasesPaget disease of the bone: – This is a condition that causes abnormal bone

tissue to form in one or more bones. – Affected bones are heavy and thick but are weaker

than normal bones and are more likely to break.

Risk factors• Certain bone diseases

Multiple hereditary – Osteochondromas.

o These are benign bone tumors formed by bone and cartilage.

o The more osteochondromas a person has, the greater the risk of developing osteosarcoma.

Risk factors• Inherited cancer syndromes

Retinoblastoma – a rare eye cancer of children that can be hereditary.

The inherited form of retinoblastoma is caused by a mutation (abnormal copy) of the RB1 gene.

The Li-Fraumeni syndrome – Makes people much more likely to develop several

types of cancer, including breast cancer, brain cancer, osteosarcoma, and other types of sarcoma. Most of those cases are caused by a mutation of the TP53 tumor suppressor gene.

Rothmund-Thompson syndrome. – Children with this syndrome are short and tend to have

skeletal problems and rashes. They also are more likely to develop osteosarcoma. This syndrome is caused by abnormal changes in the REQL4 gene.

Incidence• Osteosarcoma is uncommon but an average of 8,000

cases a year is diagnosed in the United States • And in the Philippines it was found out that the

incidence of osteosarcoma is second to India which has the highest incidence of osteosarcoma in Asia from the years 1983-1997 but after that there was no updates on the incidence of osteosarcoma in the Philippines after that year.

Types of Osteosarcoma• Localized Osteosarcoma - Cancer cells have not spread

beyond the bone or nearby tissue in which cancer began• Metastatic Osteosarcoma- Cancer cells have spread from the

bone in which the cancer began to the other parts of the body.*Multifocal Osteosarcoma- tumor appear in 2 or more bones.

• Recurrent Osteosarcoma- osteosarcoma which recurs after osteosarcoma has been cured which usually develops in other parts of the body.

Prognosis:Depends on the extent of disease, the size and location of the tumor, presence or absence of metastases, tumor’s response to therapy, age and overall health, tolerance to specific medications and new developments of treatment. It is divided into three groups:– Stage 1/Low grade, localized tumors- osteosarcoma is rare and

includes periosteal sarcoma. Has excellent prognosis >90% with wide resection

– Stage II/High grade localized tumors- prognosis depends on the site of the tumor, size of the tumor and degree of necrosis from neoadjuvant therapy.

If metastases is present the longer time to metastasis has better prognosis and even better if fewer metastases. 40-50% has a good prognosis in these stage

– Stage III/Metastatic tumors- With the presence of lung metastasis prognosis depends on the respectability of the primary tumor and lung, degree of necrosis of the primary tumor and number of metastasis prognosis in this stage is 30%

Pathophysiology

Medical Management • DIAGNOSTIC PROCEDURES

– Physical Exam, Initially, the physician will have to take a complete medical history asking the patient about heredity, risk factors and other pressing issues that are related to the condition. The assessment includes physical examination to look for possible signs of Osteosarcoma and other health problems.

– Blood Test. Doctors usually order a series of blood tests that include a complete blood count, alkaline phosphates and lactate dehydrogenase. CBC is done to determine the blood counts of the patient.

Management continuation…• Magnetic resonance imaging (MRI) scan on the affected area

also ordered, wherein they could obtain a specific or obtain the best spot to perform biopsy and to check whether the cancer had spread from the bone to near fats and tissues (metastasis has taken place).

• The most used procedure to confirm osteosarcoma is through a BIOPSY wherein they will aspirate a sample of the tumor in needle biopsy but commonly samples are obtained through an open biopsy where they take a part of the tumor or the tumor itself. This is also used to determine the histologic features and cell type of the tumor.

• If a diagnosis of osteosarcoma is made, the doctor will order a CT scan particularly chest, Radionuclide bone scan are ordered to check the extent of metastasis.

Treatment• The standard therapy for osteosarcoma is surgery with chemotherapy given before

and after surgery. • MEDICAL MANAGEMENT

Chemotherapy• Chemotherapy is vital in the treatment of osteosarcoma. Advances

in chemotherapy over the past 30 years have been responsible for improved limb salvage and higher survival rates.

• Standard regimens include preoperative (induction) and postoperative (adjuvant) chemotherapy. Preoperative chemotherapy induces tumor necrosis in the primary tumor and provides early treatment of micro metastatic disease.

Treatment continuation…• Surgical management

– In the past, treatment usually entailed amputation above the level of the tumor. Limb salvage surgical procedures, using a metal prosthesis or cadaver allograft, are becoming a standard alternative. Studies have shown that limb salvage surgery has no adverse effects on the long-term survival of persons with osteosarcoma.

– In limb-salvage surgery, the bone and muscle affected by the osteosarcoma are removed, leaving a gap in the bone that is filled by either a bone graft (usually from the bone bank) or more often a special metal prosthesis. These can be appropriately matched to the size of the bone defect.

treatment continuation…• Limb-sparing techniquesLimb-sparing (saving) tchniques available at Mayo Clinic may include bone grafts, rotation plasty or implanting artificial (prosthetic) joints.

– Autograft (bone graft from own tissue of the patient).

– Allograft (bone graft from donor tissue). – Rotationplasty. – Prosthetic implant.

treatment continuation…

Amputation is another surgical procedure that involves either the removal of expendable bones such as the fibula, ribs, toes, ulna or the complete removal of the tumor and the affected limb.

Nursing Care PlanNursing Diagnosis: Impaired physical mobility related to pain as evidenced by limited range of motion, slowed movements and reluctance to attempt movements.Nursing Inference: due to the presence of tumor on affected parts especially the limbs it affects the joints flexibility causing limitation of movement, also due to pain felt upon exertion the client is hesitant to move thus impairing physical mobility. Nursing Goal: After 3-4 days of rendering appropriate nursing intervention, the patient will be able to increase strength and function of affected body part as will be manifested by unlimited range of motion, move freely, and decrease reluctance to attempt movements.

Nursing Interventions Rationale

Observe movement when client is unaware of observation

- To note incongruencies with reports of abilities

Provide patient with ample time to perform mobility related task.

- To promote optimal level of function.

Encourage adequate intake of fluids or nutritious foods

- To promote well being and maximize energy production

Support affected body parts or joints using pillows or rolls, foot supports, or shoes, air mattress and water bed

- To maintain position of function and reduce risk of pressure ulcers

Encourage to have enough rest during the day

- To reduce fatigue

Instruct patient in use of side rails, overhead trapeze and roller pads

- For position changes

Nursing Evaluation: After 4 days of rendering appropriate nursing intervention, the patient was able to increase strength and function of affected body part as manifested by unlimited range of motion, move freely, and decrease reluctance to attempt movements.

Nursing Care Plan• Nursing Diagnosis: Chronic pain related to nerve

compression as manifested by guarding behaviour, grimacing face and with a pain scale of 8/10.

• Nursing Inference: Due to the enlargement of the affected part it causes compression of the nerve endings thus activating the nocireceptors and due to inflammatory process it releases pain chemicals prostaglandin and bradykinin thus pain.

• Nursing Goal: After 2-3 hours of rendering nursing intervention, the client will be able to demonstrate use of relaxation techniques and diversional activities as will be manifested by absence of guarding behaviour, absence of grimacing face and a pain scale will subside to 5/10.

Nursing Responsibilities RationaleAdminister analgesics as prescribed To relieve painInstruct and assist the patient in using relaxation techniques such as focused breathing and imaging.

To distract attention and reduce tension, thus relieving the pain felt by the patient.

Provide comfort measures such as touch, repositioning, nurse’s presence, quiet environment and calm activities.

This allows the promotion of relaxation, thus relieving pain.

Encourage adequate rest To prevent fatigue that could aggravate the pain felt by the patient

Encourage verbalization of feelings about the pain.

To assess the level of pain felt by the patient so that immediate and appropriate nursing interventions can be done

Review procedure/expectation and tell patient when treatment may cause pain.

To reduce level of anxiety or fear.

Nursing Evaluation: After 3 hours of rendering nursing intervention, the client was able to demonstrate use of relaxation techniques and diversional activities as will be manifested by absence of guarding behaviour, absence of grimacing face and a pain scale will subside to 5/10.

Nursing Care Plan• Nursing Diagnosis DISTURBED BODY IMAGE

related to loss of a body part as evidenced by presence of missing body part, preoccupation with the change or loss, not looking at the loss body part, unable to socialize to other patient.

• Nursing Inference: Disturbed body image is experienced by the patient because of the loss of a limb particularly at the femur which commonly affected by the growth of carcinogenic tumor. The loss of the limb causes fear, preoccupation of the loss..

Nursing Goal After 7-14 days of rendering nursing interventions, the patient will be able to have knowledge and courage to face the loss and able to be prepared in the long-term acceptance of the situation as will be evidenced by the acquisition of wider knowledge, there will be less preoccupation of the loss and able to look the amputated area and a able to talk to other patients and others without fear in the stigma.

Nursing interventions Rationale

Evaluate level of patient’s knowledge of and anxiety related to situation. Observe emotional changes.

To be able to anticipate the proper words to use for explanation and able to address the different emotions of the patient.

Discuss meaning of loss/change to patient. A small loss may have a deep impact to the patient.

Note signs of grieving/indicators of severe or prolonged depression

In order to evaluate need for counseling or medications.

Listen to patient’s comments and responses regards to the situation

Different situations are upsetting depending to the individual’s coping skills and past experiences.

Establish therapeutic nurse-patient relationship conveying an attitude of caring and developing a sense of trust

To be able to provide a more open conversation about the situation

Encourage patient and the significant others to communicate feelings to each other

To alleviate the feelings commonly stigma of the client towards the SO and other people.

Encourage verbalization of and role play anticipated conflicts

To enhance handling of potential situations.

Nursing evaluationAfter 14 days of rendering nursing

interventions, the patient was able to have knowledge and courage to face the loss and was able to be prepared in the long-term acceptance of the situation as evidenced by acquisition of wider knowledge, there is less preoccupation of the loss and was able to look the amputated area and less stigma experienced.

Thank you for listenin

g Demandante, Gaoiran, Gonzales, Ibuos