OSTEOSARCOMA

Overview
Osteosarcoma is a type of bone cancer that begins in the cells that form bones. Osteosarcoma is most
often found in the long bones — more often the legs, but sometimes the arms — but it can start in any
bone. In very rare instances, it occurs in soft tissue outside the bone.

Osteosarcoma tends to occur in teenagers and young adults, but it can also occur in younger children
and older adults.

Treatment usually involves chemotherapy, surgery and, sometimes, radiation therapy. Doctors select
treatment options based on where the osteosarcoma starts, the size of the cancer, the type and grade of
the osteosarcoma, and whether the cancer has spread beyond the bone.

Treatment innovations for osteosarcoma have greatly improved the outlook (prognosis) for this cancer
over the years. After completion of treatment, lifelong monitoring is recommended to watch for
potential late effects of intense treatments.

Osteosarcoma Subtypes

Doctors divide osteosarcoma into three subtypes, based on what the cells look like under a microscope:

1. High-grade osteosarcoma. This is the fastest-growing type, with cells that look unusual. Most
osteosarcomas in children and teens are high-grade. The most common kinds are:
 Osteoblastic the most common type of cancer that starts in the bones. The cancer cells in these
tumors look like early forms of bone cells that normally help make new bone tissue, but the
bone tissue in an osteosarcoma is not as strong as that in normal bones.

 Chondroblastic characterized by predominant presence of chondroid matrix, which tends to

exhibit a high degree of hyaline cartilage and is intimately associated with the nonchondroid
element (osteoid or bone matrix)

 Fibroblastic Osteoid production is minimal and seen focally; although in this case, osteoid matrix
was readily found. Fibroblastic osteosarcomas are highly vascular and may resemble
hemangiopericytoma.
 2. Low-grade osteosarcoma. This subtype grows slowly. The cells look more like regular bone.
 Intramedullary or intraosseous well-differentiated are malignant, aggressive, osteogenic bone
tumors most commonly found in the distal femur or proximal tibia. Patients are typically children
or young adults that present with rapidly progressive pain and swelling.

3. Intermediate-grade osteosarcoma. This is in between high- and low-grade tumors. It’s rare. The
main type is called periosteal or juxtacortical.
•Parosteal (juxtacortical) well differentiated fibroblastic tumor that produces bone/osteoid
(immature woven bone). It arises from the surface of the bone, namely the outer layer of the
periosteum. It is slow growing and slow to metastasize.

Causes

It's not clear what causes osteosarcoma. Doctors know this cancer forms when something goes wrong in
one of the cells that are responsible for making new bone.

Osteosarcoma begins when a healthy bone cell develops changes in its DNA. A cell's DNA contains the
instructions that tell a cell what to do. The changes tell the cell to start making new bone when it isn't
needed. The result is a mass (tumor) of poorly formed bone cells that can invade and destroy healthy
body tissue. Cells can break away and spread (metastasize) throughout the body.

Signs and Symptoms:

The most common symptoms of osteosarcoma include:

 Bone pain or tenderness.

  A mass or lump (tumor) that is warm and might be felt through your skin.
 Swelling and redness at the site of your tumor.
 Increased pain with lifting (if it affects your arm).
 Limping (if it affects your leg).
 Limited movement (if it affects a joint).
 Unexplained fever.
 Broken bone (sometimes this happens after a simple movement).

Risk Factors:

The direct cause of osteosarcoma is unknown. However, there are some risk factors, including:

 Rapid bone growth: The risk of osteosarcoma increases during a child and adolescent’s growth
spurts.
 Exposure to radiation: This might have occurred from treatment for another type of cancer. This
can take a few or several years to occur.
 Genetic factors: Osteosarcoma is one of several types of rare cancers in young people. This may
be related to the retinoblastoma gene, which can be associated with eye cancers in young
children or with other tumors in children and young adults in which a mutation of the p53 gene
is involved.
 Bone infarction: This happens when there’s a lack of blood supply to your bone tissue. This
destroys the cells.

Pathophysiology:
Diagnostic Procedure:

Your healthcare provider will begin with a thorough history and physical examination. They’ll ask about
your symptoms and medical history; for example, any prior radiation treatment or whether anyone in
your family has certain hereditary conditions. They’ll also look for lumps that may be protruding from
bones.

Your healthcare provider might also use certain tests when making the diagnosis. These include:

 Blood tests: These tests can provide information about blood counts and how your organs (such
as your kidneys and liver) are working. There is no blood test to detect the presence of a bone
tumor.
 X-ray: An X-ray will be done to look for abnormal growths in your bones.
 Computed tomography (CT): CT uses computers to combine many X-ray images into cross-
sectional views of the inside of your body. This test is used to look for any tumors in your lungs.
 Magnetic resonance imaging (MRI): MRI uses a large magnet, radio waves and a computer to
create clear images of body parts. This may be ordered for more detailed pictures if an X-ray is
not normal.
 Bone scan: This test uses a small amount of radioactive material injected into your body to
identify bone disorders.
 ET scan: This test uses a special glucose tracer that shows the areas in your body where the
glucose uptake is extra high. This tracer is often taken up in high concentrations in cancer cells.
 Biopsy: This is a procedure in which a piece of tissue from the affected area is removed so that it
can be studied for cancer cells. The two most likely types of biopsy your healthcare provider will
use are a core needle biopsy or a surgical biopsy.

After your healthcare provider diagnoses osteosarcoma, the next step is to find out if the cancer cells
have spread of if they’ve remained localized. This is called “staging.” The cancer can spread through your
blood, your lymph system, or tissues. If the cancer enters your lungs, it’s still referred to as
osteosarcoma, not lung cancer. The following diagnostic tools may be used:

 X-ray: Organs such as other bones or your lungs will be X-rayed.

 Computed tomography: Another CT scan will also be performed. This is the best type of scan for
evaluating your lungs.
 PET-CT: This test combines the images from the CT scan and a PET scan.
 MRI: Another MRI may be needed to get detailed pictures of other sites of cancer.
 Bone scan: A bone scan will see if the cancer cells have spread to other bones.

Treatment:

The most common forms of treatment for osteosarcoma are:

 Surgery: During surgery, the tumor and some of the healthy tissue around it will be cut out of
the affected bone. In most cases involving the arm or leg, surgery can be done without
amputation. This is called limb-salvage surgery. These procedures may be possible in those
whose cancer has not spread beyond its original site. Sometimes, artificial implants or bone
taken from another part of your body can be used to replace the bone that was removed during
 surgery. Unfortunately, there are some cases where a section or all of an arm or leg must be
amputated. You’ll get a prosthesis (artificial limb) afterwards.
 Chemotherapy: This is the use of drugs to kill cancer cells. Chemotherapy is given before surgery
to shrink the tumor and kill any cancer cells floating around in the blood, and after surgery to
catch any cancer cells that might still be in your body. Chemotherapy before surgery is called
“neoadjuvant chemotherapy” and typically takes about 10 weeks. Chemotherapy given after
surgery to kill any remaining cancer cells is called “adjuvant chemotherapy.” The typical duration
of adjuvant chemotherapy for osteosarcoma is an additional 18 weeks.
 Radiation therapy: Sometimes radiation is used to treat osteosarcoma. This is particularly
important in areas where surgery is not possible. There are two types: external radiation therapy
and internal radiation therapy. The external kind uses a machine that points radiation at the area
of the body that is cancerous. Internal radiation therapy is where the substance is inserted via
needle or catheter. For osteosarcoma, some patients are treated with bone-seeking
radiopharmaceuticals (samarium or radium) that are taken up by the bone-forming
osteosarcoma cancer cells, delivering radiation specifically to the cancer site.
 Targeted therapy: Targeted therapy is the use of drugs that block certain proteins that are
important to cancer cells. These drugs typically don’t harm normal cells as much as
chemotherapy or radiation. Kinase inhibitor therapy, mammalian target of rapamycin inhibitors
and monoclonal antibody therapy are the most common drugs used.
 Cryosurgery: Liquid nitrogen is used to freeze and destroy cancer cells.
 Amputation: Amputation is the surgical removal of a limb. This is rare.
 Rotationplasty: This procedure is used on tumors of the distal femur, which is the area of the leg
just above the knee. The leg is partially amputated, the tumor is removed and then the lower leg
is rotated 180 degrees and reattached, using the ankle as a new knee. This converts the above-
knee to a below-knee amputation that is more functional and helps fit a prosthesis. Your
healthcare provider will discuss the cosmetic side effects if a rotationplasty is an option.

---As of March 2023, the University of East Anglia and University of Sheffield in the United Kingdom has
discovered a new study published in the Journal of Bone Oncology shows how a new drug called
‘CADD522’ blocks a gene associated with driving the cancer’s spread, in mice implanted with human
bone cancer.

The breakthrough drug increases survival rates by 50 per cent without the need for surgery or
chemotherapy. And unlike chemotherapy, it doesn’t cause toxic side effects like hair loss, tiredness and
sickness.

This drug will have further clinical trials in the near future to treat the severity of osteosarcoma.

Nursing Intervention:

Independent:

 Monitor for any signs of bleeding and febrile episodes; Note laboratory findings: WBC, platelet
count, Hct, and absolute neutrophil count. Provides knowledge on any obvious, visible presence
of bleeding or abnormal blood profile that predispose to bleeding due to bone marrow
suppression and immunosuppression resulting from chemotherapy.
  Assess the oral cavity for painful burning sensation, erythema, ulcerations, and difficulty
eating and drinking. Provides information about the effect of chemotherapy.
 Inform parents to notify the health care provider for signs of increased temperature, changes
in behavior, headache, dizziness, fatigue, pallor, bleeding episode, and exposure to a
communicable disease. Signifies a complication related to an abnormal blood profile.
 Teach handwashing techniques before providing care, using protective gear such as a mask
and gown when appropriate, providing a private room, monitor for any signs and symptoms of
infections. Prevents transmission of a microorganism to a compromised immune system during
chemotherapy if neutrophil count is less than 1,000/cu mm.
 Educate parents regarding chemotherapy’s effect on the oral mucosa and its treatment. Allows
better knowledge of the unwanted effects that may occur during chemotherapy.
 Assess the parent’s and child’s level of anxiety and how it is manifested; the necessity for
information that will relieve anxiety. Provides information about source and level of anxiety and
need for interventions to relieve it; sources for the child may be procedures, fear of mutilation or
death, and unfamiliar hospital environment and may be manifested by restlessness, inability to
play, sleep, or eat.
 Communicate with the child based on developmental age level and answer questions calmly
and honestly; use pictures, models, and drawings for explanations. Allows better
understanding and promotes trust.
 Teach parents and child about the disease process, surgical procedure, what to expect
preoperatively and postoperatively including chemotherapy and its benefits and side effects
(nausea, vomiting, diarrhea, stomatitis, alopecia, and others are possibilities but are
temporary; phantom pain). Provides information to promote understanding that will relieve fear
and anxiety; understanding of preoperative and postoperative treatments and their effect on
body image.
 Assess the child for the type of surgery and condition and healing of the stump, type of
bandaging or cast, presence of drains, type of prosthetic device, and fit. Provides information
about amputation needed to provide specific care of stump and rehabilitation.

Collaborative:

 Give the ordered chemotherapeutic drugs according to the patient’s oncologist. Educate
parents regarding chemotherapy’s effect on the oral mucosa and its treatment. Allows better
knowledge of the unwanted effects that may occur during chemotherapy.
 Apply topical analgesic as ordered before meals and encourage cool, bland, and, smooth foods
that are not spicy. Prevents trauma and discomfort.
 Observe dressing for bleeding, redness, pain, and drainage at stump area every 2 to 4 hours;
maintain dressing pressure or wrapping of the stump as advised; change dressing only if
ordered. Indicates infection or risk of hemorrhage at amputation.
 Assist the child with range-of-motion exercises daily as recommended by the physical
therapist. Promotes mobility and healing of the stump and prevents contractures.
 Maintain Trendelenburg and prone position as ordered; avoid elevation, external rotation, or
abduction of stump. Prevents deformities and contractures caused by hip flexion.
  Encourage parents and the child to continue chemotherapy and rehabilitation therapy as per
doctors advice. Promotes healing.

References:

AskMayoExpert. Musculoskeletal tumors. Mayo Clinic; 2018.

Bone cancer. National Comprehensive Cancer Network.

https://www.nccn.org/professionals/physician_gls/default.aspx. Accessed Oct. 29, 2019.

Niederhuber JE, et al., eds. Sarcomas of bone. In: Abeloff's Clinical Oncology. 6th ed. Elsevier; 2020.
https://www.clinicalkey.com. Accessed Oct. 29, 2019.

Orkin SH, et al., eds. Osteosarcoma. In: Nathan and Oski's Hematology and Oncology of Infancy and
Childhood. 8th ed. Saunders Elsevier; 2015. https://www.clinicalkey.com. Accessed Oct. 29, 2019.

NCCN member institutions. National Comprehensive Cancer Network.

https://www.nccn.org/members/network.aspx. Accessed Oct. 31, 2019.

Locations. Children's Oncology Group. https://www.childrensoncologygroup.org/index.php/locations.

Accessed Oct. 31, 2019.

Warner KJ. Allscripts EPSi. Mayo Clinic. July 18, 2019.

National Cancer Institute. General Information About Osteosarcoma and Malignant Fibrous Histiocytoma
of Bone (http://www.cancer.gov/types/bone/patient/osteosarcoma-treatment-pdq). Accessed
2/19/2021.

National Cancer Institute. Bone Cancer (http://www.cancer.gov/types/bone/bone-fact-sheet). Accessed

2/19/2021.

American Cancer Society. What is Osteosarcoma?

(https://www.cancer.org/cancer/osteosarcoma/about/what-is-osteosarcoma.html) Accessed 2/19/2021.

American Cancer Society. Osteosarcoma (https://www.cancer.org/cancer/osteosarcoma.html). Accessed

2/19/2021.

Liddy Shriver Sarcoma Initiative. Osteosarcoma: An Introduction

(http://sarcomahelp.org/osteosarcoma.html). Accessed 2/19/2021.

American Academy of Orthopedic Surgeons. Osteosarcoma (https://orthoinfo.aaos.org/en/diseases--

conditions/osteosarcoma/). Accessed 2/19/2021.

National Cancer Institute. What is Cancer? (https://www.cancer.gov/about-cancer/understanding/what-

is-cancer) Accessed 2/19/2021.
 University of Saint Anthony
(Dr. Santiago G. Ortega Memorial)
City of Iriga

SCHOOL OF GRADUATE STUDIES AND RESEARCH

SUBJECT: N230 Advance Pathophysiology

TOPIC: OSTEOSARCOMA
SEMESTER: 1st Sem (SY 2023-2024)
STUDENT: Maria Vernadette M. Florece, RN
PROFESSOR: Dr. Jane Briones Tagum

Answer the following question briefly and based on your own understanding.

1. In your own understanding, what is Osteosarcoma?

2. Give at least 3 risk factors of Osteosarcoma and explain each briefly.
3. What is your opinion regarding the new breakthrough drug ‘CADD522’ that blocks a gene
associated with driving the cancer’s spread, explain your thoughts regarding this newly
discovered drug for osteosarcoma.
4. What do you think is the most important independent nursing intervention for Osteosarcoma?
Explain your choice/s.
5. Given the predisposing factors of Osteosarcoma in the pathophysiology, what do you think is the
most common? Explain.