|
Year |
2002 |
|---|---|
|
Question Number |
151 |
|
Category |
Orthopaedic Disease |
Question
A 32-year-old man reports gradually worsening right arm pain and an enlarging mass over the medial aspect of his distal arm. A radiograph, T1-and T2-weighted coronal MRI scans, and a biopsy specimen are shown in Figures 39a through 39d. What is the most appropriate management?
1- Wide excision, radiation therapy, and chemotherapy
2- Wide excision and radiation therapy
3- Wide excision and chemotherapy
4- Wide excision only
5- Radiation therapy only
Figures
Answer (click for answer)
Preferred Response: 3
Discussion:
Osteosarcoma most commonly affects males between the ages of 10-30 with a predilection for the metaphyses of large, long bones. The distal femur, proximal tibia, humerus and radius are the four most common sites of involvement. It commonly presents as a hard, painful, enlarging mass with pathologic fracture being a rare occurrence. Patients will typically have an associated elevation of their serum alkaline phosphatase levels. Radiographically it presents as a destructive lesion with amorphic ossification and soft tissue extension is common. Microscopically it presents as spindle shaped mesenchymal cells that are immature, amorphous, and aligned in a non-stress orientation. These tumors are classified according to three main subgroups: parosteal(juxtacortical), periosteal, and high-grade surface osteosarcoma. The case given in this example is that of a high-grade surface osteosarcoma which is classically associated with the poorest prognosis, with overall survival in one study from the Mayo Clinic at 5 years being 46.1%. Treatment consists of systemic chemotherapy and surgery. If the patient is responsive to preoperative chemotherapy, a wide en bloc resection is indicated, otherwise radical excision and amputation must be performed.
Reference: Okada K, Unni KK, Swee RG, Sim FH: High grade surface osteosarcoma: A clinicopathologic study of 46 cases. Cancer 1999;85:1044-1054.