Osteosarcoma of the Jaws

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