Metastatic Osteosarcoma with Intracranial and Pulmonary Involvement
Year: 2024
Type: article
Study design: Case Report
Abstract: Sir, Osteosarcoma is a malignant bone tumor that predominantly affects children and young adults.[1] The development of metastases, particularly to the brain and lungs, is associated with a poor prognosis.[2] We report a case of a young male patient with metastatic osteosarcoma who presented with intracranial lesions, respiratory symptoms, and neurological deterioration. The subsequent management challenges due to patient reluctance and the ethical dilemmas surrounding patient autonomy and decision-making are discussed. A 25-year-old male patient who was initially diagnosed with osteosarcoma of the fibula and underwent tumor resection, subsequently received chemotherapy and radiotherapy, presented to the emergency department with a 2-month history of cough, breathlessness, and fever, which had worsened over the past 2 days. The patient complained of upper and lower limb weakness and had experienced a generalized tonic-clonic seizure. On examination, decreased air entry was noted on the left side of the chest. Neurological assessment revealed left upper limb paralysis (0/5 power) and left lower limb weakness (2/5 power). The Glasgow Coma Scale (GCS) score was 15/15, and the pupils were equal and reactive to light. Magnetic resonance imaging (MRI) of the brain [Figure 1] revealed a large, well-defined oval lesion in the right posterior frontal region with surrounding edema and areas of calcification or hemorrhage suggestive of metastases.[3] A computed tomography (CT) scan of the chest [Figure 2] showed multiple metastatic lesions in both hemithoraxes, with the larger lesion occupying the entire left hemithorax, causing mediastinal compression and shifting towards the right. In addition, a left adrenal metastasis was observed.Figure 1: Revealed a large, well-defined oval lesion in the right posterior frontal region with surrounding edema and areas of calcification or hemorrhage, suggestive of metastasesFigure 2: Multiple metastatic lesions in both hemithorax, with the larger lesion occupying the entire left hemithorax, causing mediastinal compression and shifting towards the rightMANAGEMENT AND OUTCOME A multidisciplinary approach involving specialists in pulmonary medicine, neurosurgery, and general medicine was sought. Neurosurgery advised conservative management with antiepileptics, antiedema measures, and steroids. The patient was subsequently transferred to the medical intensive care unit (MICU). However, the patient’s condition continued to deteriorate, necessitating endotracheal intubation and further management. Despite explaining the poor prognosis, the patient’s attendants expressed reluctance to continue treatment and insisted on going against medical advice. DISCUSSION Metastatic osteosarcoma is a complex disease that often requires a multidisciplinary approach involving specialists from various fields to determine the most appropriate treatment strategy. In this case, the patient developed intracranial and pulmonary metastases, leading to significant respiratory distress and neurological deficits. The management options for metastatic osteosarcoma include surgical interventions, radiation therapy, and systemic therapies such as chemotherapy.[2] However, in some cases, conservative management with palliative measures and supportive care may be considered, particularly when the disease is advanced and the prognosis is poor. In this case, despite recommendations for conservative management, the patient’s condition continued to deteriorate. The attendants, likely acting as the patient’s surrogate decision-makers, expressed reluctance to continue with the recommended treatment. This situation raises important ethical considerations and highlights the delicate balance between respecting patient autonomy and ensuring the best interests of the patient. Respecting patient autonomy is a fundamental principle in medical ethics, empowering patients to make informed decisions about their healthcare.[3] Patients have the right to accept or refuse medical treatments, even if the decisions may appear to be against medical advice. However, healthcare providers have an ethical obligation to engage in a thorough and open discussion with the patient or their surrogate decision-makers, providing all relevant information about the diagnosis, treatment options, potential benefits, risks, and prognosis.[4] It is crucial to consider the patient’s values, beliefs, and goals of care when exploring treatment options and decision-making. In this case, the attendants’ reluctance to continue treatment may stem from various factors, such as their perception of the patient’s quality of life, concerns about treatment burden, financial constraints, or cultural and religious beliefs. It is important for healthcare providers to acknowledge and address these concerns, aiming to establish a shared understanding and collaborative decision-making process.[5] This may involve providing additional information, clarifying misconceptions, involving palliative care specialists to address symptom management and quality of life, and exploring alternative treatment options that align with the patient’s goals and values. While respecting patient autonomy is crucial, healthcare providers must also consider the potential harms and risks of decisions that go against recommended medical advice. In cases where patient decisions may lead to significant harm or compromise the patient’s well-being, healthcare providers may need to engage in further discussions, involve ethics consultations, or explore legal frameworks to ensure the best interests of the patient are upheld. It is important to note that the role of healthcare providers is not only limited to respecting patient autonomy but also includes advocating for the patient’s welfare and providing medical expertise. In challenging situations where there is a conflict between patient autonomy and the medical team’s recommendations, open and transparent communication, empathy, and shared decision-making become even more crucial to arrive at an ethically sound and patient-centered approach. CONCLUSION Metastatic osteosarcoma remains a formidable challenge in clinical practice. This case report highlights the difficulties encountered in managing such cases, especially when patients present with intracranial lesions and complications leading to patient reluctance and decisions to go against medical advice. Declaration of patient consent The authors certify that they have obtained appropriate patient consent in the form, images, and other clinical information to be reported in the journal. Patient understands that his name and initials will not be published to conceal his identity, but anonymity cannot be guaranteed. Data availability statement All data is available as part of article and no additional source data are required. Author contribution Dr. Ajay: Writing original draft, review and editing and final draft; Dr. Varsha Shinde: Supervision, proof Reading. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Authors: Ajay Pawar, Varsha S. Shinde
Language: English
Subfield: Pulmonary and Respiratory Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W4402579974