Elbow Reconstruction For Distal Humerus Osteosarcoma

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 Traumatology Faculty of Medicine University of Indonesia

• Malignant bone tumors are rare lesions : – RSCM →1,3% of all the cancer load (Errol UH, unpublished data, 2006) – Mayo Clinic → 1-2%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 malignant bone tumors after multiple myeloma Æ19% Dahlin’s bone tumors general aspects and data on 11,087 cases.1996. pp.143pp.143-95

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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

Æ designed g to accomplish p removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic, functional, and cosmetic result J Am Acad Orthop Surg 2003;11:252003;11:25-37.

FIRST CASE A 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 status Mass : • 26 cm in circumferential length g ((20 cm in the 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 Æ neoadjuvant chemotherapy • Planned for limb salvage surgery using an extracorporeal irradiation of distal humerus

Limb Salvage Surgery First 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 & 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 screw • 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 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 CASE Woman, 30 yo • History of recurrent lump at left distal humerus th t was getting that tti bigger bi since i 2 years ago 9 years ago (1997)

2 years ago (April 2004)

4 months b.a

• a 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) • Firm, tenderness, fixed with illdefined 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) • Diagnosed Di d as reccurrentt parosteal t l osteosarcoma • Planned to limb salvage procedure using extra corporeal irradiation autograft f • 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 byy fixed them into the proximal shaft with plate and screw • Olecranon was fixed with the tension band wire • Common flexor and extensor origins were sutered 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 disarticulation → dismal survival rate 10-20% Dahlin’s bone tumors general aspects and data on 11,087 cases.1996. pp.143pp.143-95. J Am Acad Orthop Surg 2003;11:252003;11:25-37.

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Development of : • Effective chemotherapeutic agents • CT and MRI Ð Allow precise visualization of the anatomic location of tumor and surrounding structures Ð Better patient selection for spesific treatment of limb salvage procedure J Am Acad Orthop Surg 2003;11:252003;11:25-37.

Consideration of Limb Salvage Procedure : 1. An upper extremity tumor → needs resection 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] 1996;78 1996;78--B:652 B:652--57.

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Limb Salvage Surgery First Stage : • Resection R ti off th the h halflf di distal t l humerus that contain tumor • Osteotomy of olecranon, • Conservation of nervus & muscle groups, except the muscle attached to the tumor tumor. • The resected humerus sent to BATAN for irradiation with dose 30,000 rads

Second Stage : • Reconstruction R t ti off th the half distal humerus with plate & screw • Fixation of the olecranon with TBW • Sutured the common flexor and extensor origins to the original sites • Radiohumeral joint was fixed with the K wire for temporary

Result I. Conventional osteosarcoma Ð 1 Neoadjuvant 1. N dj t chemotherapy 2. Limb salvage surgery 3. Evaluation of neoadjuvant chemotherapy agents revealed to unresponder group (HUVOS I) Æ change to another chemotherapy g agents Ð Result in 1st mo : ROM of elbow joint 35-75° Ð Follow-up : Elbow joint function

II. Parosteal osteosarcoma Ð 1. Limb salvage surgery directly 2. No chemotherapy before Ð Result : ROM of elbow joint 30-90° Ð Follow-up Follow up : Elbow joint function

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• The 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 satisfaction appear to be at least as good, and probably better after reconstruction than after ablation

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