Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Osteosarcoma of the Jaws Osteosarc. 1 Sept. 2003 Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Osteosarcoma of the Jaws • Work-up procedure • TNM staging • Primary treatment • Follow-up • Treatment of recurrent and/or metastatic disease • Appendix: surgical techniques • References Osteosarc. 2 Sept. 2003 Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Standard clinical evaluation • Complete history of the disease • Weight and weight loss • Performance status (Karnofsky or WHO scale) • General, Head and Neck examination • Evaluation of cranial nerves V2, V3, VII, XII • Drawing of all lesions on a common template • Biopsy under local or general anesthesia after imaging Osteosarc. 3 Sept. 2003 Evidence Option Type C Type C Type C Type C Type C Type C Type C Std. Std. Std. Std. Std. Std. Std. Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Advanced clinical evaluation l l l Osteosarc. 4 Sept. 2003 Dental examination by oral surgeon Prosthetic rehabilitation (if maxillectomy) Nutritional assessment Evidence Option Type C Type C Type C Std. Std. Std. Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Laboratory tests • Hemogram, ionogram, coagulation tests, liver enzymes, kidney function Osteosarc. 5 Sept. 2003 Evidence Option Type C Std. Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Local Imaging and metastatic work-up • Orthopantomogram (+ dental X-Rays if needed) • MRI (jaw and neck) + CT Scan (bone without contrast enhancement) • Thoracic spiral CT • Bone scintigraphy Osteosarc. 6 Sept. 2003 window Evidence Option Type C Type C Std. Std. Type C Type C Std. Std. Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Osteosarcoma of the Jaws • Work-up procedure • TNM staging • Primary treatment • Follow-up • Treatment of recurrent and/or metastatic disease • Appendix: surgical techniques • References Osteosarc. 7 Sept. 2003 Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Staging • TNM classification (AJCC 2002) Osteosarc. 8 Sept. 2003 Evidence Option Type C Std. Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme TNM/AJCC 2002 Staging • TX: Primary tumor cannot be assessed • T0: No evidence of primary tumor • T1: Tumor 8 cm or less in greatest dimension • T2: Tumor > 8 cm in greatest dimension • T3: Discontinuous tumors in the primary bone site Osteosarc. 9 Sept. 2003 Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme TNM/AJCC 2002 Staging • NX:Regional lymph nodes cannot be assessed • N0: No regional lymph node metastasis • N1: Regional lymph node metastasis Osteosarc. 10 Sept. 2003 Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme TNM/AJCC 2002 Staging • MX: Distant metastasis cannot be assessed • M0: No distant metastasis • M1: Distant metastasis • M1a : Lung • M1b : Other distant metastasis, including lymph nodes Osteosarc. 11 Sept. 2003 Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Osteosarcoma of the Jaws • Work-up procedure • TNM staging • Primary treatment • Follow-up • Treatment of recurrent and/or metastatic disease • Appendix: surgical techniques Osteosarc. 12 Sept. 2003 • References Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Treatment Evidence Option Type 3 Type 3 Type 3 Std. Std. Ind. Type 3 Std. • Any T, N0, M0 low grade (G1): surgery high grade (G2-G3): induction chemotherapy + surgery ± post-op RxTh • Any T, N1-M1 chemotherapy1 + surgery2 (T, N, M) if possible 1See See recommendations for chemotherapy on slide 22 See surgical techniques on slides 18 and 19 2See Osteosarc. 13 Sept. 2003 Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Osteosarcoma of the Jaws • Work-up procedure • TNM staging • Primary treatment • Follow-up • Treatment of recurrent and/or metastatic disease • Appendix: surgical techniques • References Osteosarc. 14 Sept. 2003 Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Follow-up • Clinical examination of head and neck mucosa and neck palpation/ performance status/nutritionnal assessment: every 2 months (first 2 years), every 6 months (years 3-5), once a year ( > 5 year) • Dental examination and orthopantomogram every 6 months • Chest spiral CT every year • MRI head and neck every year during the first 5 years • Evolution of late toxicity (CTC scale) Osteosarc. 15 Sept. 2003 Evidence Option Type C Std. Type C Std. Type C Type C Type C Std. Std. Std. Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Osteosarcoma of the Jaws • Work-up procedure • TNM staging • Primary treatment • Follow-up • Treatment of recurrent and/or metastatic disease • Appendix: surgical techniques Osteosarc. 16 Sept. 2003 • References Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Salvage treatment for loco-regional disease • Palliative care • Chemotherapy1/ surgery2/ RxTh Evidence Option Type C Type C Std. Ind. Evidence Option Type C Type C Std. Ind. 1See See recommendations for chemotherapy on slide 22 See surgical techniques on slides 18 and 19 2See Salvage treatment for metastatic disease • Chemotherapy1 • Surgery2 of the metastasis if possible 1See See recommendations for chemotherapy on slide 22 2See surgical techniques on slides 18 and 19 Osteosarc. 17 Sept. 2003 Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Osteosarcoma of the Jaws • Work-up procedure • TNM staging • Primary treatment • Follow-up • Treatment of recurrent and/or metastatic disease • Appendix: - Surgical techniques - Recommendations for pathological examinations - Recommendations for chemotherapy Osteosarc. 18 Sept. 2003 • References Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Surgical techniques (2 slides) - Radical surgery - mandibulectomy (extended) - maxillectomy (extended) -… Osteosarc. 19 Sept. 2003 Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Surgical techniques - Reconstruction Primary if - good prognosis - Radicality with Free flaps (fibula, iliac crest) - If no primary reconstruction : • Reconstruction plate (AO or THORP) • Maxillary obturator prosthesis Osteosarc. 20 Sept. 2003 Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Recommendations for pathological examinations (2 slides) • • • Osteosarc. 21 Sept. 2003 Macroscopy: - 2-10 cm Pathology: - atypical cuboidal or polyhedric cells - osseous material which can be osteoid or bone Classification: - tumoral differentiation: osteoblastic, chondroblastic, fibroblastic - cytological atypia (Broders): grade I to IV Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Recommendations for pathological examinations • Osteosarc. 22 Sept. 2003 Analysis of surgical specimen - precise tumour extension and resection margins - confirm or modify the degree of atypia and the differentiation - identify a preexisting lesion - appreciate effects of chemotherapy: % of necrosis Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Recommendations for Chemotherapy (1 slide) • • Osteosarc. 23 Sept. 2003 Localized osteosarcoma - Cisplatin 100 mg/m2 J1 and adriamycin 25 mg/m2, J1-J2-J3, 6 cycles every 3 weeks Metastatic osteosarcoma - More intensive chemotherapy with cisplatin, high dose MTX, high dose Ifosfamide and adriamycin + surgery of the primary site and the metastasis if feasible Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Osteosarcoma of the Jaws • Work-up procedure • TNM staging • Primary treatment • Follow-up • Treatment of recurrent and/or metastatic disease • Appendix: surgical techniques Osteosarc. 24 Sept. 2003 • References Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme AJCC Cancer Staging Manual. Springer, New York. Sixth Edition, 2002 • Bennett JH, Evans AW, Speight PM. Osteosarcoma of the jaws: A 30-year retrospective review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000; 90 : 323-333. • Daw NC, Mahmoud HH, Meyer WH, Jenkins JJ, Kaste SC, Poquette CA, Kun LE, Pratt CB, Rao BN. Bone sarcomas of the Head and Neck in children. The St. Jude Children’s Research Hospital experience. Cancer 2000; 88 : 2172-2180. • Gadwal SR, Gannon FH, Fanburg-Smith JC, Becoskie EM, Thompson LDR. Primary osteosarcoma of the Head and Neck in pediatric patients. A clinicopathologic study of 22 cases with a review of the literature. Cancer 2001; 91 : 598-605. • Kassir RR, Rassekh CH, Kinsella JB, Segas J, Carrau RL. Osteosarcoma of the Head and Neck: Meta-analysis of nonrandomized studies. Laryngoscope 1997; 107 : 56-61. • Oda W, Bavisotto LM, Schmidt RA, McNutt M, Bruckner JD, Conrad III EU, Weymuller EA. Head and Neck osteosarcoma at the University of Washington. Head Neck 1997; 19 : 513-523. • Smeele LE, Kostense PJ, van der Waal I, Snow GB. Effect of chemotherapy on survival of craniofacial osteosarcoma: A systematic review of 201 patients. J Clin Oncol 1997; 15 : 363-367. • van Es RJJ, Keus RB, van der Waal I, Koole R, Vermey A. Osteosarcoma of the jaw bones. Long term follow-up of 48 cases. Int J Oral Maxillofac Surg 1997; 26 : 191-197. • Osteosarc. 25 Sept. 2003
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