01.09 Osteosarcoma

Hey guys! Today we are going to review Osteosarcoma. By the end of this lesson, you’ll understand what osteosarcoma is, the types of patients you will see this in, assessment findings, treatment options, and nursing considerations relating to this disease process.

So just to give you a broad overview - osteosarcoma or osteogenic sarcoma is type of bone cancer that is found in the metaphysis of long bones and is commonly seen in children and young adults. Ok so let’s look at this picture here. Here are the different sections of bone - epiphysis, diaphysis, and metaphysis which is where osteosarcoma begins. It’s commonly seen in the distal femur, proximal tibia, and humerus. It’s important to keep in mind that it usually metastasizes or spreads to the periphery of the lung within just 2 years of treatment. These cases are really pretty sad when you think about it, and metastasis leads to death in most cases. Osteosarcoma is the most common bone cancer in children and is most common in patients 10-25 years of age.

Diagnosis usually starts with an x-ray. This picture does an excellent job of showing osteosarcoma in the tibia. So right here you can see the tumor and can see it’s not a nice clean pretty bone like the femur up here. A CT scan can help evaluate the extent of soft tissue damage. A MRI could also be ordered for difficult to visualize areas. A needle biopsy allows for the cancer to be staged for size and degree of spread.

Let’s talk about some of the assessment findings you’ll see with osteosarcoma. So first, patients will have pain that usually is described as severe or dull localized acute pain. It’s usually relieved by a flexed position - so bending the extremity usually makes the pain better. With the generally vague pain complaints, the pain is commonly attributed to trauma or growing pains. There could be some swelling and you may be able to actually palpate the mass. There could also be some warmth you could feel to the affected area as well. Patients will also have musculoskeletal changes, so assessing mobility and ability to perform ADLs is important. Pain can cause limping if a weight bearing limb is affected as well as limited range of motion. Increased pain could indicate pathological fractures at the tumor site, so this is important to consider as well.

A big part of management is to reduce the size or to remove the tumor entirely. Radiation is the treatment of choice in early osteosarcoma as it reduces both the size of tumor and pain. Chemo can be used before and after surgery and is used to kill the rapidly growing cancer cells. If chemo is administered, make sure to monitor for potential complications that can occur with treatment. Surgical resection reduces the size of tumors or can remove them entirely, such as in a limb salvage procedure where the goal is to save the limb and remove the affected tissue. Usually surgery is combined with radiation or chemo for the most effective results. Depending on the size of resection, an implant or allograft may be needed. Just to review, an allograft is a tissue graft from a donor - typically from cadavers. Depending on the extent of tumor invasion, amputation may be indicated. Osteosarcoma is one of the most common reasons for amputation in children. Pathologic fractures are caused by metastatic bone and are very painful so pain control is a treatment priority. Wound care could be indicated if surgery is performed or if there are wounds from infection. Make sure to monitor for infection and perform neurovascular checks just like we do with other surgical procedures. Depending on disease progression, patients may choose palliative treatment vs curative treatment if the prognosis is poor or if there is metastasis.

There is a lot of anxiety and uncertainty that comes with this diagnosis, so education can help patients and families feel empowered. Educate about the type of treatment ordered, what to expect, and potential complications that can occur. Educate about wound care and PICC line maintenance if applicable. Teach about pain medications available to address the patient’s pain. If amputation is indicated, educate about prosthetic fitting and phantom limb pain. Patients can have problems coping with their diagnosis, so emphasize the importance of verbalizing their feelings in support groups and to a good support system. Patients should ease back into activities gradually and some activities like sports may be prohibited to prevent injury. Educate about things that can be done to help with self image like wearing long pants if a patient is self conscious about a leg prosthetic. Reinforce that patients should attend all appointments and should adhere to their treatment regimen. Sometimes treatment is not effective and death is imminent. In these cases the focus turns to comfort vs curative. Provide anticipatory guidance and educate about comfort as well as pain and symptom control. Hospice is available for terminal cancer to aid in comfort and to guide the patient and family through the patient’s last moments.

The priority nursing concepts for a patient with osteosarcoma include coping, comfort, and functional ability. Coping is a nursing concept because this diagnosis causes alterations in self image, and can cause other psychological issues. Comfort is a nursing priority because these patients are in pain. Functional ability is a nursing priority because it can affect their mobility, ability to complete ADLs, and range of motion.

The key points I want you to remember include diagnostic testing, whether it’s with x-ray, CT, MRI, or needle biopsy. We need to know what we’re dealing with to move on to the available treatment options like radiation, chemo, surgical resection, and amputation. We will educate a lot about the prescribed treatment and regimen, pain control, and providing anticipatory guidance. The last key point I want you guys to keep in mind is regarding coping with the diagnosis. So make sure to educate about support groups available, emphasize the importance of verbalizing feelings and having a good support system as well. Educate what returning to ‘normal’ life will look like. It will be a new ‘normal’ for the patient and family, so educating how to cope, things to try, etc is healing and very helpful for the patients and their families.

Alright guys, that’s it for our lesson on osteosarcoma. Make sure to check out the other resources attached to this lesson. Now, go out and be your best self today. And, as always, Happy Nursing!