SNAKE BITE

Disusun Oleh:
Ilma Syifannisa

Pembimbing:
dr. Dini S Warsodoedi, Sp.B

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FAKULTAS KEDOKTERAN UNSWAGATI
Snakebites are well
Snake Bite
known medical
emergencies and a
cause of hospital
admission in many
countries.

South-East Asia
Region is one of
the world’s most
affected regions

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Prevention
Inside the house
• Don’t keep livestok (e.g. chicken)
inside house
• Store food in rodent-proof continers
• Avoid types of house construction that
will provide snakes with hiding place
• Avoid sleeping unprotected on the
ground

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75% cases of
osteosarcoma
occurs in long bone.

Source:
https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiD1_fyjK_ZAhWKUrwKHf

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 Genetics Factor of Osteosarcoma
• Mutation of TP53
(encodes p53
proteins)

e.g. Found in Lin-

Fraumeni Syndrome

Source:
https://www.google.com/url?sa=i&rnijj8u8yu87y7y7yct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiD1_fyj
K_ZAhWKUrwKHfZ0BP0Qjh

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• RB1 in 13q14
microdeletion

e.g found in hereditary

retinoblastoma

Source:
https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiD1_fyjK_ZAhWKUrwKHf
Z0BP0Qjh

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• Mutation in RecQ helicase
protein
e.g. found in Bloom’s Syndrome,
Werner’s syndrome, Rothmund-
Thomson Syndrome

Source:
https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiD1_fyjK_ZAhWKUrwKHf
Z0BP0Qjh

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• Wnt/B-catenin and src pathways
• Fas/Fas ligand pathway

Both, will made the prognosis of osteosarcoma

worse

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 SYMPTOMPS
• pain in the affected area.
• Pain during sleep,
• enlarging mass, and
• worsening pain without clear signs of infection
or injury are particularly worrisome signs
• weight loss, malaise and fever

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 SIGNS
• palpable mass,
• restricted joint motion,
• Pain with weight bearing, or
• localized warmth/erythema

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 WORK UP
• X-ray imaging of affected extremity
• High level of Alkaline Phosphatase (ALK-P)
• Hiigh level of Lactate Dehydrogenase (LDH)
• MRI to see invasion
• Biopsy

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AP (a) and lateral (b) X-rays of an 11-year-old patient with an osteosarcoma of the distal
femur. Note the wide zone of transition, discontinuous periosteal reaction, and areas of
increased mineralization

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a Coronal images showing the extent of the marrow abnormality and the soft-tissue
mass which appears hypointense on T1 imaging. b STIR imaging illustrating the reaction
zone of peritumoral inflammation

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Medium-power (a) and high-power (b) microscopic images of an osteosarcoma
specimen, showing high cellularity, nuclear polymorphism, atypia, and disorganized
osteoid production

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X-ray (a) and MRI (b) of the distal femur of a 13-year-old girl, showing a large
solitary lesion

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staging with bone scan (c) and MRI
(d) revealed additional skip
metastasis in her ipsilateral femur
diaphysis and peritrochanteric area
that was not detected with initial
imaging.

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The presence of the skip metastases changed the surgical plan from a distal femur
resection to an entire femur resection and reconstruction (e)

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 Therapy
Neoadjuvant Adjuvant
Surgery
chemotherapy chemotherapy
(operative)
(pre-operative) (post-operative)

more time to fabricate - Limb Salvage Surgery to prevent the

endoprosthetic devices, - Amputation recurrence and
decreased tumor size, metastasis
and permitted an
analysis of the surgical
specimen for its
response to
chemotherapy

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 Chemotherapy Regimen
• methotrexate, adriamycin, and cisplatin 
standard regimen in USA and Europe
• Some institution use ifosfamide with or
without etoposide. But show more toxicity
• Radiation used in unresectable cases

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 Surgery
• All tumors should be removed with a wide
margin to prevent residual disease
• Following resection, pathological specimens
are examined to see the effect that
chemotherapy  if necrosis >= 90%, the
prognosis is good.

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Amputation vs Limb Salvage Surgery
Benefit:
Benefit: Good functional outcome
Simple procedure Good psychological and
cosmetics
Disadvantage:
- Infection Disadvantage:
- Chronic painful limb - Risk infection
- Phantom limb - DVT
- Peri prosthetic fracture
- Non-union
- Multiple surgery

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• Old  amputation was
believed to be necessary
to control local disease
• Now  as advances in
chemotherapy, imaging,
and reconstruction
techniques have made
limb salvage surgeries
more feasible

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 LSS
• Resection arthrodosis
• Allograft
• Endoprosthesis
• Rotationplasty

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 Allografts
• Implants slowly undergo variable rates of osseous
and vascular integration by the body and have a
theoretical advantage of being a permanent
replacement for the resected bone
• Failure rates can be as high as 17–20% due to
infection, nonunion, or implant fracture.
• union rates are decreased by radiotherapy,
chemotherapy, and poor nutritional states

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 A matching allograft was used to fill the defect
and fixed to the patient’s remaining bone

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 Two-year follow-up shows robust union at the
junction sites

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 Endoprosthesis
• choice in many centers
• Most are modular, allowing a degree of
customization that can be adjusted
intraoperatively to match the anatomic needs
of each patient
• stable postoperatively for early mobilization
• devices are a lifelong infection risk, since the
reconstruction is nonbiological

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• Resection of the tumor mass was performed with care taken to spare the
neurovascular bundle (b), and then the defect was reconstructed with a
proximal tibia endoprosthesis (c) and a medial gastrocnemius muscle flap
for soft-tissue coverage (d)

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• An 11-year-oldmale patient with a large osteosarcoma of the distal femur that was
reconstructed with an expandable endoprosthesis. Preop (a), immediate postop
(b), and 2-year postoperative (c) X-ray images are shown. A lengthening of almost
5 cm was achieved with the expandable construct by age 13

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 Rotationplasty
• option in patients with distal femur OS
• Only few patients and parents choose this
type of amputation

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 Post-operative Observation
• The National Comprehensive Cancer Network
(NCCN) recommends imaging of both the
chest and the surgical site as often as every 3
months during the first 2 years
• 20–30% of patients who presented with
recurrence localized disease
• 80% of patients who presented with
metastasis within the first 3 years

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 Prognosis
• Survival rates for patients with OS increased
dramatically with the introduction of
chemotherapy
• 5-year survival for all patient groups with high-
grade OS is 60–66%
• survival drops to 20–30% for those with
metastatic disease

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 NEW THERAPY
• mTOR inhibitor: Sirolimus and Everolimus
• VEGFR, PDGFR inhibitor: papozanib and
sorafenib
• Fas pathway activating: Interleukin 12 (IL-12)
• Endogenous IL-12 inducer: Liposomal
muramyl tripeptide phosphatidyl
ethanolamine (liposomal MTP-PE)
• Bisphosphonates: zoledronate

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 Conclussion
Advances in chemotherapy and surgery have taken OS from an
almost universally fatal disease to one in which the majority of
patients will survive with a meaningful quality of life. Despite this,
a fair number of those affected will still develop fatal metastatic
disease or serious complications of treatment, emphasizing the
need for further clinical advancements. Accurate and efficient
diagnosis, preoperative chemotherapy, surgical resection,
postoperative chemotherapy, and lifelong surveillance are all vital
in managing this complicated and potentially deadly disease.

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 THANK YOU 

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