Osteogenic sarcoma

Abstract

Christopher Mitchell, MB, MRCPThe purpose of today's Tumor Board discussion is to consider current options for treatment of osteogenic sarcoma as illustrated by a patient recently seen at the Children's Hospital of Philadelphia (CHP), and to discuss the optimal management of this condition today.A 13-year-old white girl first came to medical attention when she complained of left thigh pain and swelling which had begun 4 weeks earlier. The only previous medical problem of note was a 1-year period of observation for scoliosis. Examination at an outside hospital was normal except for a swollen and tender left thigh. A roentgenogram of the left femur showed bony destruction located in the diaphysis. A chest x-ray revealed a single, right-sided pulmonary nodule at the level of the ninth rib. This finding was confirmed by a computerized tomographic (CT) scan; no other nodules were seen. A radionuclide bone scan showed uptake in the left femur. Biopsy revealed the presence of osteogenic sarcoma, and she was then referred to CHP for further treatment.Pre-operative chemotherapy was administered, consisting of four courses of high-dose methotrexate, followed by two courses of bleomycin, cyclophosphamide and actinomycin D. During this period, serial chest xrays showed no progression of disease and she experienced relief of pain in her left thigh. She subsequently underwent a limb-salvage procedure and then continued the adjuvant chemotherapy. Subsequent CT scans showed development of further pulmonary metastases. Two and one-half months after resection of the primary tumor, she underwent bilateraI thoracotomies. A total of 31 nodules were removed from the parenchyma of both lungs. She then received further chemotherapy, but her chest x-ray films subsequently showed progressive pulmonary disease. She received two further courses of high-dose methotrexate without response. Chemotherapy was then discontinued. At present she is receiving only supportive care.Dr. Ellis, would you please outline the surgical considerations in this condition and the orthopedic treatment of this patient? Ronald D. Ellis, MD (Pediatric Orthopedic Surgeon)