I. INTRODUCTION

A case of Cecil Casem, 28 years old, married, high school graduate and from Luna, La

Union. She was to consider Osteosarcoma after so many diagnostic procedures done to her. The

results was then confirmed in other hospitals to have this disease. On April 16, 2012, patient had

undergone Hip Disarticulation on the right knee.

Osteosarcoma is a deadly form of musculoskeletal cancer that most commonly causes

patients to die from pulmonary metastatic disease and which has a 5-year survival rate of 15-

20%. It is regarded to be the most common highly malignant bone tumor which often affects the

adolescents and young adults. The symptoms and chances of recovery for children and

adolescents appear to be the same.

Radiography is almost always the initial imaging modality used in the investigation and

with histolopathologic studies done for the definitive diagnosis. The present management for

osteogenic sarcoma involves amputation or disarticulation collaborated with chemotherapy.

Etiology

Rapid bone growth appears to predispose persons to osteosarcoma, as suggested by the

increased incidence during the adolescent growth spurt, and osteosarcoma’s typical location in

the metaphyseal area adjacent to the growth plate (physis) of long bones.

There are some evidences of genetic predisposition for osteosarcoma in patients with

bone dysplasia (Paget disease, fibrous dysplasia, enchondromatosis, and hereditary multiple

exostoses and retinoblastoma). It is thought that the combination of constitutional mutation of

the RB gene and radiation therapy might develop chances for osteogenic mutation. The only

known environmental risk factor is exposure to radiation. But in most cases of osteogenic

sarcoma no definite cause can be determined.

Clinical Presentation

Pain, as a rule the first symptom, is of dull, constant, aching character and often interferes

with sleep. The usual physical examination findings include a palpable mass which may or may

not be present. The mass may be tender and warm, though these signs are indistinguishable from

osteomyelitis. In the case of lower limb lesions, the discomfort may result in a slight limp.

Pathologic fracture is uncommon in osteogenic sarcoma. In rapidly growing tumors, distention of

the superficial veins and elevation of the skin temperature over the lesion are common.

Pulsations or a bruit may sometimes be detectable. The range of motion might be decreased if a

joint is involved. Involvement of local or regional lymph nodes is unusual. Auscultation is

usually uninformative unless disease is extensive. In more than half of patients the serum

alkaline phosphatase level is elevated, reflecting the osteoblastic activity of the tumor cells.

Incidence

The incidence of osteosarcoma is slightly higher in males than in females with males (5.2

per million per year) and females (4.5 per million per year). It is very rare in young children (0.5

cases per million per year in children <5 y), incidence increases steadily with age, increasing

more dramatically in adolescence, corresponding with the growth spurt.

Treatment

The orthopedic surgeon is of paramount importance in the care of patients with

osteosarcoma. Since osteosarcomas are not particularly responsive to radiotherapy, surgery is

the only option for definitive tumor removal (local control). In addition, an oncologic type of

total joint prosthesis or complex bone reconstruction may be required following surgical

resection. Therefore, close involvement of the orthopedic surgeon with the medical oncologist at

the time of diagnosis, as well as during and after chemotherapy, is critical.

The primary aim of definitive resection is patient survival. As such the margins on all

sides of the tumor must contain normal tissue (wide margin). The thickness of the margin is

important only for the marrow, where an adequate margin is thought to be 5-7 cm from the edge

of abnormality depicted on MRI or bone scan. But amputation may be the treatment of choice in

some circumstances.

When amputation is decided, a well planned rehabilitative program should be designed in

partnership with the physiatrist and physical therapist for the patient’s post-amputation recovery.

The most important prognostic factor for long-term survival is response to chemotherapy.

Preoperative (neoadjuvant) chemotherapy followed by limb-sparing surgery (which can be

accomplished in > 80% of patients) followed by postoperative (postadjuvant) chemotherapy is

standard management. The use of neoadjuvant chemotherapy has been found to facilitate

subsequent surgical removal by causing tumor shrinkage and has also provided oncologists with

an important risk parameter. Patients who have a good histopathological response to neoadjuvant

chemotherapy (>95% tumor cell kill or necrosis) have a better prognosis than those whose

tumors do not respond as favorably. The effective drugs are doxorubicin, ifosfamide, cisplatin,

and high-dose methotrexate with leucoverin rescue.

Prognosis

The present understanding of outcome and prognosis for osteosarcoma is driven by

certain serum markers, clinical staging, and histologic response to chemotherapeutic agents. The

overall 5-year survival rate for patients diagnosed between 1974 and 1994 was 63% (59% for

males, 70% for females). Patients with elevated alkaline phosphatase at diagnosis are more

likely to have pulmonary metastases. In patients without metastases, those with an elevated LDH

are less likely to do well than are those with a normal LDH. Long term survival rates in

extremity osteosarcoma range from 60 to 80%. Osteosarcoma is radioresistant; radiation therapy

has no role in the routine management.

II. OBJECTIVE

General Objective

The purpose of this study is to analyze and improve understanding of, to develop

necessary nursing skills and to apply the appropriate nursing care while maintaining

confidentiality of patient having Osteosarcoma.

Specific Objective

To present a case of osteosarcoma in a 28 year old patient.

To understand condition about Osteosarcoma.

To improve our physical assessment skill in patient with Osteosarcoma.

To correlate laboratory results to its normal value.

To illustrate the anatomy and physiology of the affected part or organ

To know the pathophysiology of the case.

To be aware of the causes, clinical manifestations and complications.

To formulate a drug study with regards to the patient’s condition.

To develop effective nursing skill on how to manage proper care to a patient with this

kind of disease

To provide client a nursing care plan and discharged plan to assure total wellness during

hospitalization, up to the time of discharge.

III. PATIENT’S PROFILE

Name : Cecil Casem

Address : Luna, La Union

Age : 28years old

Birthday : September 15, 1983

Nationality : Filipino

Religion : Born Again

Occupation : Housekeeper

Spouse : Amante Casem

Date& Time of Admission : April 10, 2012 @ 6:55 PM

Admitting Diagnosis : To consider osteosarcoma right Knee

Admitting Physician : Dr. Eric Piscawen

IV. PAST AND PRESENT ILLNESS

Present Illness

1 year prior to admission, patient noted a slowly growing mass on the right knee which

initially was associated with pain or tenderness and there was limitation of motion noted. The

condition was tolerated and no consultation sought because of financial restraints.

Few months prior to admission, patient started to complain of dull, constant, aching pain

with progressive increase in the size of the mass in the right kneee. The pain was also

aggravated during ambulation. She was brought to Lorma for consultation and done some

diagnostic procedure like X-ray, MRI and CT scan according to the patient. Patient brought to

ITRMC for reassurance to the disease. She has then diagnosed benign cancer.

1 month PTA, patient was then brought again by his husband for consultation where an

open biopsy was advised. Patient complied open biopsy and confirmed on other hospital in

Manila and revealed osteosarcoma. She was then advised for surgery and thus this admission.

Past Illness

a. Childhood illness

Fever

Cough and cold

Mumps

Chicken fox

Measles

b. Immunizations

Complete immunization

c. Allergies

No known allergies to foods

d. Accidents

With no previous accident

e. Hospitalizations

With no previous hospitalization

V. PHYSICAL ASSESSMENT

PARAMETERS NORMAL FINDINGS

ACTUAL FINDINGS

INTERPRETATION

General Appearance -clean in appearance and well groomed

- cooperative

>Endomorphic built

>Intact and Dry dressing

>Weak in appearance

>Conscious and coherent

Due to the disease process

Skin - with good skin turgor

>Good skin turgor With normal findings

Hair -evenly distributed hair

-thick hair

> evenly distributed hair

>thick hair

With normal findings

Nails - with good capillary refill of 1-2 seconds

-with pinkish nail beds

-with clean and short nails

>With good capillary refill of 2-3 sec.

>With clean and short nails

With normal findings

Skull and face -mouth uniform consistency; absence of nodules and masses

-rounded smooth skull contour

-symmetrical facial movement

>mouth uniform consistency; absence of nodules and masses

>rounded smooth skull contour

>symmetrical facial movement

With normal findings

Eyes -no eye discharge

-eyebrows hair evenly distributed/skin

intact

- (+) blink reflex

-with pinkish conjunctiva

>With slightly pale conjunctiva

Due to poor sleeping habits brought about by Osteosarcoma

Ears

-auricle color same

>Without discharges With normal findings

as facial skin

-auricle are mobile firm and not tender

-able to hear on both ears

-no edema and discharge

>able to hear on both ears

Mouth -pinkish lips

-without missing teeth

-with pink gums

-no foul odor

-with symmetrical contour

>With dry lips Due to poor intake of foods

Musculoskeletal (upper and lower extremities)

-symmetrical

-no atrophy

-with full range of motion

>amputated hip at right knee

>phantom pain

Due to surgical operation done

Abdomen -no abdominal distention

-flat rounded abdomen

-symmetrical contour

-no surgical incision

>With soft and non-tender abdomen upon palpation

>abdominal muscle weakness

Due to limited motion

VI. ANATOMY AND PHYSIOLOGY

The skeletal system provides support and protection, allows body movements, stores

minerals and fats, and is the site of blood cell production.

Four types of bone tissue:

Long bones - are longer than they are wide, most of the bones of the upper and lower limbs

are long bones. Examples: femur, tibia, and fibula of the leg, the humerus, radius, and ulna

of the arm, and the phalanges of the fingers and toes.

Short bones- -are approximately are broad as they are long, such as the bones of the wrist

and ankles.

Flat bones - -have a relatively thin and flattened shape.

Irregular bones - include the vertebrae and facial bones, with shapes that do not readily fit

into three other categories.

There are two kinds of bone tissue:

Compact bone - is the hard material that makes up the shaft of long bones and the

outside surfaces of other bones.

Spongy bone - consists of thin, irregularly shaped plates called trabeculae, arranged in a

latticework network.

Parts of the long bones:

Diaphysis

-a long tubular portion of long bones, it is composed of compact bone tissue. It has the

medullary cavity or marrow cavity, an open area within the diaphysis, the adipose tissue

inside the cavity stores lipids and forms the yellow marrow.

Epiphysis

-the expanded end of a long bone

Metaphysis

-is the area where the diaphysis meets the epiphysis. It includes the epiphyseal line, a

remnant of cartilage from growing bones.

Layers of bone tissue:

Periosteum

-is the membrane covering the outside of the diaphysis (and epiphyses where

articular cartilage is absent). It contains osteoblasts (bone-forming cells), osteoclasts

(bone-destroying cells), nerve fibers, and blood and lymphatic vessels. Ligaments and

tendons attach to the periosteum.

Endosteum

-is the membrane that lines the marrow cavity.

VII. PATHOPHYSIOLOGY

BOOK BASED

CLIENT BASED

CausesDNA mutation injury

infection metabolic or hormonal disturbance

Risk Factorsrepeated traumatall for the agehereditary abnormalities including Paget's diseaseexposure to ionizing irradiation associated with radiation therapy family history of certain types of cancer

Osteoblast

Malignant Osteoblast (abnormal)

High grade mecenchymal tumor

Distal femur

Proximal tibiaProliferation of abnormal osteoblast

Formation of osteoid or immature bone(thin, wispy and purposeless fragment of bone)

Pain, swelling, tenderness Bulky tumor that destroys trabeculae of disease area

Metastasize through bloodstreamLungs, bones, visceral organs

VIII. DIAGNOSTIC PROCEDURE

>gender>ageactivity

Malignant neoplasm/tumor arising in the tissue of mesodermal origin

Dilatation of vessels Elevation of periosteum

Bone mass

Pathologic fracture

> pain> swelling> limited motion

surgical biopsy

malignant

Balanced Skeletal Traction

OSTEOSARCOMA

>sales lady>labandera>house helper

Fake healer

Some of her diagnostic procedures are not present in her chart. Only Complete Blood

Count and Hematology are compiled on her chart.

Complete Blood Count

Results Normal Findings

Hg 110 g/L 120 – 160 g/L

Hct 33 vol % 38 – 47 vol %

Hematology

Results Normal Findings

WBC 5.61 x 109/L 4.00 – 10.00

RBC 3.49 x 1012/L 4 – 5.50

Hgb 102 g/L 120 – 160

Hct 31.7 % 40 – 54

PCT 577 x 109/L 150 - 450

Multiple imaging studies of the tumor and sites of possible metastasis, such as:

x-rays - a diagnostic test that uses invisible electromagnetic energy beams to produce images of

internal tissues, bones, and organs onto film

bone scans - a nuclear imaging method to evaluate any degenerative and/or arthritic changes in

the joints; to detect bone diseases and tumors; to determine the cause of bone pain or

inflammation. This test is to rule out any infection or fractures.

magnetic resonance imaging (MRI) - a diagnostic procedure that uses a combination of large

magnets, radiofrequencies, and a computer to produce detailed images of organs and

structures within the body. This test is done to rule out any associated abnormalities of

the spinal cord and nerves.

computed tomography scan (Also called a CT or CAT scan) - a diagnostic imaging procedure

that uses a combination of x-rays and computer technology to produce cross-sectional

images (often called slices), both horizontally and vertically, of the body. A CT scan

shows detailed images of any part of the body, including the bones, muscles, fat, and

organs. CT scans are more detailed than general x-rays.

biopsy of the tumor

XI. DISCHARGED PLANNING

Medication

Cefalexin 500mg i cap TID

Environment/Economic Status/Exercise

a. Maintain a quiet, clean and calm environment for easy and good recovery of the

patient.

b.Provide safety measure

c. Place bedside urinals near patient’s bed for easy access when nature calls.

d. Patient has middle economic status and they need for extra job for the medication.

e. Have regular exercise

T reatment

Health Teaching

Provide with normal growth and development activities

Advise patient to take the medicine continuously at home.

Advise patient to avoid lifting heavy objects and use of too much force to prevent

more serious injury.

Avoid strenuous activities.

Proper personal hygiene.

The importance of exercise on both extremities.

Instruct to do deep breathing and coughing exercises.

OPD

After discharge, advice patient to come back to specific date said by the doctor

Diet

High protein and rich in vitamin C foods to promote healing.

XII. EVALUATION

The patient is now recovering from her surgery. She is experiencing phantom pain after it

and she can’t accept of the missing part of her body. But after few nursing care plan rendered to

her, she accept what happened and from now on she is able to trust God and more stronger than

before.

Student nurse, I am now knowledgeable about Osteosarcoma on how it affects the body,

the causes, the risk factors and the clinical manifestation of the disease. I also find out the

treatments and procedures suited for patients with osteosarcoma. I’m able to render some of the

nursing care plan for her.

XIII. BIBLIOGRAPHY

1. eMedicine Online

2. Wikipedia

3. Google

4. Physical Assessment Book