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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(Errol UH, unpublished data, 2006) – Mayo Clinic → 1-2%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

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Local statusMass :• 26 cm in circumferential

length (20 cm in the g (health tissue)

• Firm, tenderness, fixed with ill-defined margin

Laboratory• CBC : normal • ESR : 29mm/h • SAP : 161 u/l (40 – 150) • LDH : 303 u/m (230–460)

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

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