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  1. Osteogenic sarcoma is the most common malignant bone tumor in children & adolescents. It occurs most frequently in 2nd decade.
  2. It arises in the medullary cavity of metaphysis of a long bone, mostly in lower end femur followed by upper end tibia.
  3. It is the most common primary bone tumor causing pulmonary metastases (micrometastasis present in almost 90% cases).
  4. Lymphatic metastatses may occur but not so common
  5. Sunburst/ sunray appearance is produced by formation of spicules of new bone laid down perpendicular to the shaft along the vessels passing from the periosteum to the cortex. Codman’s triangle (d/t periosteal elevation) are typical of osteosarcoma, they may occasionally be seen in other rapidly growing tumors.
  6. Lab investigation raised serum alkaline phosphatase and raised LDH (Indicator of poor prognosis).
  7. It is highly radio resistant and ideally treated by chemotherapy followed by limb salvage surgery/amputation followed by chemotherapy.

T-10 Protocol for osteosarcoma includes

  1. HDMTX - High Dose Methotrexate
  2. VCR: Vincristine
  3. BCD: Bleomycin, Cyclophospimide, Dactinomycin (Actinomycin D)
  4. DOX: Doxorubicin
  5. CDDP: Cisplatin

Cisplatin is substituted for methotrexate in patients with poor response to methotrexate containing induction therapy.


Osteosarcoma distal femur with characterstic sunburst apperance

Secondary osteosarcoma is seen in

  1. Paget’s disease
  2. Bone dysplsia egfibrous dysplasia
  3. Post radiation
  4. Bone infarction
  5. Survivors of retinoblastoma

Juxtacortical — Parosteal Osteosarcoma

  1. It is a low grade fibroblastic osteosarcoma, which appears to occur in relatively older age group (i.e. young adults) The lesion makes up 4% of all osteosarcomas, but occurs at a later age and most commonly in females.
  2. Better prognosis
  3. Most common site of occurrence is posterior aspect of distal femur. Wide surgical en block excision /amputation without chemotherapy is the treatment of choice.

Ewing’s Sarcoma

It is a type of PNET (Primitive Neuro Ectodermal Tumor, also called small round cell tumors).


T(11:22) this kind of translocation differentiate it with other round cell tumor.


Most common location is diaphysis, around the knee.

  1. Clinical Feature
    Classical presentation is like osteomyelitis
    1. Mostly in males between 10-20 years of age (5-30 yrs range)
    2. May appear in any bone or occasionally soft tissue but most present in diaphysis of femur.
    3. Systemic symptoms such as fever, generalized weakness, weight loss, anemia, leukocytosis, LDH & raised ESR are hallmark of fulminating course, advanced disease or metastasis.
    4. 50% of all metastases occurs to lung & 25% to bone & bone marrow
    5. If found in less than 5 year of age should also consider wilms tumor and if found more than 30 year of age should also consider lymphoma.
  2. Radiological Finding
    1. Mottled rarefaction of spongiosa with permeation of overlying cortex, reflecting rapid bone destruction is the principal finding
    2. Laminated (layered) periosteal new bone formation onion- peel appearance
    3. Soft tissue masse, indicating neoplasm has perforated cortex
    4. Mostly diaphyseal but may extend into metaphysis.

Ewing’s Sarcoma with characteristic onion skin appearance

  1. Treatment
    1. Highly radiosensitive (melts on RT) but overall survival is not much enhanced
    2. Chemotherapy is much more effective & include vincristine, actinomycin D, cytoxan, adriamycin, ifosamide & etoposide
    3. Best results are achieved by
      • Preoperative chemotherapy; then wide excision (or amputation) if tumor is in favourable site and further chemotherapy for 1 years.
      • Radiotherapy followed by local excision if it is in less accessible site & then further chemotherapy for 1 year.
  1. Poor prognostic factor in Ewing sarcoma
    1. Spine / Pelvic tumor
    2. Size more than 8cm
    3. Less than 90% necrosis with chemotherapy (most important factor)
    4. Raised LDH
    5. Fever
    6. Anemia
    7. Male: age > than 15
Extra Edge: Small round cell tumor differential diagnosis
  1. Less than 5 year  neuroblastoma
  2. 5 – 10 year  Eosinophilic granuloma
  3. 5 – 30  Ewing sarcoma
  4. More than 30  lymphoma
  5. More than 50  myeloma

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