1. Caso 2-2004: Un varón de 32-Años-de-Edad Con Dolor e Inflamación de la Mandíbula Thomas B. Dodson, Paul A. Caruso, y G. Petur Nielsen Dodson T et al. Case 2-2004: A 32-Year-Old Man with Pain and Swelling of the Jaw. The New England Journal of Medicine 2004;350:267-75. De los Departamentos de Cirugía (T.B.D.), Radiología (P.A.C.), y Patología (G.P.N.) Oral y Maxilofacial, Hospital General de Massachusetts; y los Departamentos de Radiología (P.A.C.) y Patología (G.P.N.), Escuela Médica de Harvard. R 2 . Abell Sovero Gaspar
4. PRESENTACIÓN DEL CASO Dr. H. Daniel Clark (Cirugía Oral y Maxilofacial): * Rx. Pps. 9 años antes: Pzas. 43 y 32 inclinadss y lig. desplazadss. * Pac. consciente de dientes “chuecos” hace 8 años y pensó recién que posición divergente estaba empeorando. * Referido a este hospital. * Estaba bien de otras cosas. * Única medicación: Finasteride. * Era ejecutivo, bebia alcohol pero nunca había fumado. * No historia familiar de tumores malignos.
5. PRESENTACIÓN DEL CASO Dr. H. Daniel Clark (Cirugía Oral y Maxilofacial): * Pulso = 65 lat. x minuto y Pr sanguínea = 135/65 mm Hg. * Examen físico: no asimetría facial. * Mucosa azul-rojizo profundo en reg. de pzas. 43 a 32. Ligera inflamación y sensibilidad en lingual cerca al sitio de Bx.
14. ASOCIACIÓN CON ESTRUCTURAS ADYACENTES Wood NK, Goaz PW. Diagnóstico diferencial de las lesiones orales y maxilofaciales. .4th edn, St. Louis: Mosby 1997. Langlais R, Langland O. Diagnostic imaging of the jaws. .1st ed., Williams and Wilkins 1995.
15. ASOCIACIÓN CON ESTRUCTURAS ADYACENTES Wood NK, Goaz PW. Diagnóstico diferencial de las lesiones orales y maxilofaciales. .4th edn, St. Louis: Mosby 1997. Langlais R, Langland O. Diagnostic imaging of the jaws. .1st ed., Williams and Wilkins 1995.
16. PATRONES LÍTICOS GEOGRÁFICO Langlais R, Langland O. Diagnostic imaging of the jaws. .1st ed., Williams and Wilkins 1995.
17. PATRONES LÍTICOS APOLILLADO Langlais R, Langland O. Diagnostic imaging of the jaws. .1st ed., Williams and Wilkins 1995.
32. ASOCIACIÓN CON ESTRUCTURAS DENTARIAS DIENTE FLOTANTE DESPLAZAMIENTO Wood NK, Goaz PW. Diagnóstico diferencial de las lesiones orales y maxilofaciales. .4th edn, St. Louis: Mosby 1997. Langlais R, Langland O. Diagnostic imaging of the jaws. .1st ed., Williams and Wilkins 1995.
33. DIENTE FLOTANTE ENFERMEDAD PERIODONTAL NEOPLASIA MALIGNA Wood NK, Goaz PW. Diagnóstico diferencial de las lesiones orales y maxilofaciales. .4th edn, St. Louis: Mosby 1997. Langlais R, Langland O. Diagnostic imaging of the jaws. .1st ed., Williams and Wilkins 1995.
34. 1985 1987 1994 1997 Varón 41a Nair MK et al. Radiographic manifestation of clear cell odontogenic tumor. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:250-4.
35. REACCIÓN PERIOSTAL LAMELAR NO INTERRUMPIDA Langlais R, Langland O. Diagnostic imaging of the jaws. .1st ed., Williams and Wilkins 1995.
36. REACCIÓN PERIOSTAL PIEL DE CEBOLLA Langlais R, Langland O. Diagnostic imaging of the jaws. .1st ed., Williams and Wilkins 1995.
37. REACCIÓN PERIOSTAL LAMELAR INTERRUMPIDO Langlais R, Langland O. Diagnostic imaging of the jaws. .1st ed., Williams and Wilkins 1995.
38. REACCIÓN PERIOSTAL TRIÁNGULO DE CODMAN Langlais R, Langland O. Diagnostic imaging of the jaws. .1st ed., Williams and Wilkins 1995.
51. DISCUSIÓN DEL MANEJO Osteosarcoma de la mandíbula: * Intento x desarrollar Plan Tx. Herramienta de manejo clínico basado en evidencia: Ejercicio valuación crítica. - 1er paso: Método de formular buena pregunta clínica: PICO P = paciente o población I = intervención C = grupo control o de comparación O = resultado (outcome). “ ¿Entre pacientes (P) con osteosarcoma de mandíbula, aquellos que reciben terapia adyuvante (I), comparado con aquellos que solo sufren cirugía (C), sobreviven más tiempo (O)?”
52. DISCUSIÓN DEL MANEJO Ejercicio valuación crítica: * 2do paso: Buscar la literatura. - Forma + eficiente de completar búsqueda: Citas de publicaciones 2rias donde ya hayan completado ejercicios de valuación crítica u otras sinopsis de varias preguntas y temas clínicos. - Medline + Software de búsqueda: filtros para identificación de artículos de alta calidad relacionados a historia natural, pronóstico, Dx., etiología, y terapia. Búsquedas complejas en tiempo corto. - Versiones Full-text de citas clave obtenidas electrónicamente.
53. DISCUSIÓN DEL MANEJO Ejercicio valuación crítica: * 3er paso: “Jerarquía de la Evidencia” Opiniones de expertos sin valuación crítica explícita Opiniones basadas en la fisiología, investigación de banca, o "principios primarios" (principios fisiopatología usados para dirigir la práctica clínica) 5 Series de caso 4 Estudios caso-control 3 Investigación de resultados de estudios cohorte 2 Pruebas clínicas aleatorizadas 1 Tipo de Evidencia Nivel Niveles de Evidencia para Sustentar las Decisiones de Tratamiento
54. DISCUSIÓN DEL MANEJO Ejercicio valuación crítica: * 3er paso: “Jerarquía de la Evidencia” - Calidad de evidencia fue pobre. - Series de caso retrospectivos: * Unos cuantos pacientes c/ año de instituciones únicas * Estudios derivados de datos combinantes de muchas instituciones Evidencia nivel-4. - Grandes espacios de tiempo de estos estudios (unos 37 años) — han evolucionado esquemas diagnósticos, de clasificación, y de Tx Difícil evaluar los resultados.
55. DISCUSIÓN DEL MANEJO Osteosarcoma de la mandíbula: Ejercicio valuación crítica. * Un artículo resumió y tabuló hallazgos de 23 estudios: 1er recurso. * Brevemente rastree artículos restantes para identificar “perlas” clínicas que ayuden a guiar o sustentar recomendaciones del Tx. * Kassir y col. 9 identificaron 23 estudios, reportando datos de Tx. Y supervivencia; 163 pacs. y autores añadieron 15 pacs. adicionales de su propia institución. - Supervivencia media pac. tratados sólo con resección = 60 meses - Cx. + terapia adyuvante = 24 meses.
56.
57. DISCUSIÓN DEL MANEJO Ejercicio valuación crítica: * 4to paso: Recomendar una estrategia de Tx. * Paciente con factores pronósticos favorables: joven y tumor de grado bajo- a-intermedio y pequeño: - Tx. 1rio Qx: resección en bloque con márgenes adecuados (> 5 mm). - Reevaluar variables pronósticas en base a hallazgos en examen patológico de especimen Qx.. - Márgenes negativos radioterapia adyuvante (asegurar control local y disminuir riesgo de recurrencia local. - Márgenes positivos Cx. adicional seguido x radioterapia adyuvante (control local) y quimioterapia adyuvante (prevención de enfermedad metastásica a distancia. - Si lesión es grande (> 10 cm) o tumor de alto-grado quimioterapia inclusive con márgenes negativos.
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73. "In science the credit goes to the man who convinces the world, not to the man to whom the idea first occurs.” “ One of the first duties of the physician is to educate the masses not to take medicine.” “ What the brain does not know, the eye cannot see” SIR WILLIAN OSLER
Dr. David C. Harmon (Hematology–Oncology): In the absence of information from controlled trials to define the role of chemotherapy in this setting, the patient and I had extensive discussions and reviewed some of the available research concerning osteosarcoma of the jaw. Most reports indicated a high mortality rate, but recent reports of treatment involving radical resection seemed more optimistic. In a series at this institution, 5 a trend toward improved survival among patients who received chemotherapy was noted. A more recent, larger series from Memorial Sloan-Kettering Cancer Center 6 also suggested an improvement with the more aggressive, combined-treatment approach now in use. The few randomized trials of chemotherapy in osteosarcoma involved patients with large lesions in the arms or legs. Adjuvant chemotherapy substantially improves the cure rates in that high-risk setting. The toxicity, inconvenience, and expense of chemotherapy — close to a year of treatment with high-dose methotrexate, doxorubicin, cisplatin, and ifosfamide or similar drugs — are substantial. Nevertheless, even a 10 percent improvement in the cure rate would more than offset the small but real risk of death from chemotherapy. After consideration, this patient thought that chemotherapy was worth a try. Varvares performed immediate reconstruction with a vascularized, composite flap of bone and soft tissue from the fibula. The bony fragments were stabilized with a new rigid reconstruction plate. The tissue from the fibula was transferred to the site, and arterial and venous anastomoses were constructed with the use of an operating microscope (Fig. 5). Pathological examination of the excised tissue revealed no residual tumor. Dr. Dodson: Dr. Kaban, will you comment? Dr. Leonard B. Kaban (Oral and Maxillofacial Surgery): This very difficult case illustrates the many challenges clinicians encounter in managing primary jaw tumors of mesenchymal origin. These tumors can occur in both young and old persons and have a spectrum of clinical behavior that ranges from benign to locally aggressive to malignant. The histologic diagnoses include fibro-osseous lesions, atypical fibro-osseous lesions, aggressive fibromatoses, desmoplastic fibroma, myxoma, fibromyxoma, fibrosarcoma, and osteosarcoma. There are no Bone Graft and Titanium Reconstruction Plate.
Dr. David C. Harmon (Hematology–Oncology): In the absence of information from controlled trials to define the role of chemotherapy in this setting, the patient and I had extensive discussions and reviewed some of the available research concerning osteosarcoma of the jaw. Most reports indicated a high mortality rate, but recent reports of treatment involving radical resection seemed more optimistic. In a series at this institution, 5 a trend toward improved survival among patients who received chemotherapy was noted. A more recent, larger series from Memorial Sloan-Kettering Cancer Center 6 also suggested an improvement with the more aggressive, combined-treatment approach now in use. The few randomized trials of chemotherapy in osteosarcoma involved patients with large lesions in the arms or legs. Adjuvant chemotherapy substantially improves the cure rates in that high-risk setting. The toxicity, inconvenience, and expense of chemotherapy — close to a year of treatment with high-dose methotrexate, doxorubicin, cisplatin, and ifosfamide or similar drugs — are substantial. Nevertheless, even a 10 percent improvement in the cure rate would more than offset the small but real risk of death from chemotherapy. After consideration, this patient thought that chemotherapy was worth a try. Varvares performed immediate reconstruction with a vascularized, composite flap of bone and soft tissue from the fibula. The bony fragments were stabilized with a new rigid reconstruction plate. The tissue from the fibula was transferred to the site, and arterial and venous anastomoses were constructed with the use of an operating microscope (Fig. 5). Pathological examination of the excised tissue revealed no residual tumor. Dr. Dodson: Dr. Kaban, will you comment? Dr. Leonard B. Kaban (Oral and Maxillofacial Surgery): This very difficult case illustrates the many challenges clinicians encounter in managing primary jaw tumors of mesenchymal origin. These tumors can occur in both young and old persons and have a spectrum of clinical behavior that ranges from benign to locally aggressive to malignant. The histologic diagnoses include fibro-osseous lesions, atypical fibro-osseous lesions, aggressive fibromatoses, desmoplastic fibroma, myxoma, fibromyxoma, fibrosarcoma, and osteosarcoma. There are no Bone Graft and Titanium Reconstruction Plate.
Dr. David C. Harmon (Hematology–Oncology): In the absence of information from controlled trials to define the role of chemotherapy in this setting, the patient and I had extensive discussions and reviewed some of the available research concerning osteosarcoma of the jaw. Most reports indicated a high mortality rate, but recent reports of treatment involving radical resection seemed more optimistic. In a series at this institution, 5 a trend toward improved survival among patients who received chemotherapy was noted. A more recent, larger series from Memorial Sloan-Kettering Cancer Center 6 also suggested an improvement with the more aggressive, combined-treatment approach now in use. The few randomized trials of chemotherapy in osteosarcoma involved patients with large lesions in the arms or legs. Adjuvant chemotherapy substantially improves the cure rates in that high-risk setting. The toxicity, inconvenience, and expense of chemotherapy — close to a year of treatment with high-dose methotrexate, doxorubicin, cisplatin, and ifosfamide or similar drugs — are substantial. Nevertheless, even a 10 percent improvement in the cure rate would more than offset the small but real risk of death from chemotherapy. After consideration, this patient thought that chemotherapy was worth a try. Varvares performed immediate reconstruction with a vascularized, composite flap of bone and soft tissue from the fibula. The bony fragments were stabilized with a new rigid reconstruction plate. The tissue from the fibula was transferred to the site, and arterial and venous anastomoses were constructed with the use of an operating microscope (Fig. 5). Pathological examination of the excised tissue revealed no residual tumor. Dr. Dodson: Dr. Kaban, will you comment? Dr. Leonard B. Kaban (Oral and Maxillofacial Surgery): This very difficult case illustrates the many challenges clinicians encounter in managing primary jaw tumors of mesenchymal origin. These tumors can occur in both young and old persons and have a spectrum of clinical behavior that ranges from benign to locally aggressive to malignant. The histologic diagnoses include fibro-osseous lesions, atypical fibro-osseous lesions, aggressive fibromatoses, desmoplastic fibroma, myxoma, fibromyxoma, fibrosarcoma, and osteosarcoma. There are no Bone Graft and Titanium Reconstruction Plate.
Dr. David C. Harmon (Hematology–Oncology): In the absence of information from controlled trials to define the role of chemotherapy in this setting, the patient and I had extensive discussions and reviewed some of the available research concerning osteosarcoma of the jaw. Most reports indicated a high mortality rate, but recent reports of treatment involving radical resection seemed more optimistic. In a series at this institution, 5 a trend toward improved survival among patients who received chemotherapy was noted. A more recent, larger series from Memorial Sloan-Kettering Cancer Center 6 also suggested an improvement with the more aggressive, combined-treatment approach now in use. The few randomized trials of chemotherapy in osteosarcoma involved patients with large lesions in the arms or legs. Adjuvant chemotherapy substantially improves the cure rates in that high-risk setting. The toxicity, inconvenience, and expense of chemotherapy — close to a year of treatment with high-dose methotrexate, doxorubicin, cisplatin, and ifosfamide or similar drugs — are substantial. Nevertheless, even a 10 percent improvement in the cure rate would more than offset the small but real risk of death from chemotherapy. After consideration, this patient thought that chemotherapy was worth a try. Varvares performed immediate reconstruction with a vascularized, composite flap of bone and soft tissue from the fibula. The bony fragments were stabilized with a new rigid reconstruction plate. The tissue from the fibula was transferred to the site, and arterial and venous anastomoses were constructed with the use of an operating microscope (Fig. 5). Pathological examination of the excised tissue revealed no residual tumor. Dr. Dodson: Dr. Kaban, will you comment? Dr. Leonard B. Kaban (Oral and Maxillofacial Surgery): This very difficult case illustrates the many challenges clinicians encounter in managing primary jaw tumors of mesenchymal origin. These tumors can occur in both young and old persons and have a spectrum of clinical behavior that ranges from benign to locally aggressive to malignant. The histologic diagnoses include fibro-osseous lesions, atypical fibro-osseous lesions, aggressive fibromatoses, desmoplastic fibroma, myxoma, fibromyxoma, fibrosarcoma, and osteosarcoma. There are no Bone Graft and Titanium Reconstruction Plate.
Dr. David C. Harmon (Hematology–Oncology): In the absence of information from controlled trials to define the role of chemotherapy in this setting, the patient and I had extensive discussions and reviewed some of the available research concerning osteosarcoma of the jaw. Most reports indicated a high mortality rate, but recent reports of treatment involving radical resection seemed more optimistic. In a series at this institution, 5 a trend toward improved survival among patients who received chemotherapy was noted. A more recent, larger series from Memorial Sloan-Kettering Cancer Center 6 also suggested an improvement with the more aggressive, combined-treatment approach now in use. The few randomized trials of chemotherapy in osteosarcoma involved patients with large lesions in the arms or legs. Adjuvant chemotherapy substantially improves the cure rates in that high-risk setting. The toxicity, inconvenience, and expense of chemotherapy — close to a year of treatment with high-dose methotrexate, doxorubicin, cisplatin, and ifosfamide or similar drugs — are substantial. Nevertheless, even a 10 percent improvement in the cure rate would more than offset the small but real risk of death from chemotherapy. After consideration, this patient thought that chemotherapy was worth a try. Varvares performed immediate reconstruction with a vascularized, composite flap of bone and soft tissue from the fibula. The bony fragments were stabilized with a new rigid reconstruction plate. The tissue from the fibula was transferred to the site, and arterial and venous anastomoses were constructed with the use of an operating microscope (Fig. 5). Pathological examination of the excised tissue revealed no residual tumor. Dr. Dodson: Dr. Kaban, will you comment? Dr. Leonard B. Kaban (Oral and Maxillofacial Surgery): This very difficult case illustrates the many challenges clinicians encounter in managing primary jaw tumors of mesenchymal origin. These tumors can occur in both young and old persons and have a spectrum of clinical behavior that ranges from benign to locally aggressive to malignant. The histologic diagnoses include fibro-osseous lesions, atypical fibro-osseous lesions, aggressive fibromatoses, desmoplastic fibroma, myxoma, fibromyxoma, fibrosarcoma, and osteosarcoma. There are no Bone Graft and Titanium Reconstruction Plate.
Dr. David C. Harmon (Hematology–Oncology): In the absence of information from controlled trials to define the role of chemotherapy in this setting, the patient and I had extensive discussions and reviewed some of the available research concerning osteosarcoma of the jaw. Most reports indicated a high mortality rate, but recent reports of treatment involving radical resection seemed more optimistic. In a series at this institution, 5 a trend toward improved survival among patients who received chemotherapy was noted. A more recent, larger series from Memorial Sloan-Kettering Cancer Center 6 also suggested an improvement with the more aggressive, combined-treatment approach now in use. The few randomized trials of chemotherapy in osteosarcoma involved patients with large lesions in the arms or legs. Adjuvant chemotherapy substantially improves the cure rates in that high-risk setting. The toxicity, inconvenience, and expense of chemotherapy — close to a year of treatment with high-dose methotrexate, doxorubicin, cisplatin, and ifosfamide or similar drugs — are substantial. Nevertheless, even a 10 percent improvement in the cure rate would more than offset the small but real risk of death from chemotherapy. After consideration, this patient thought that chemotherapy was worth a try. Varvares performed immediate reconstruction with a vascularized, composite flap of bone and soft tissue from the fibula. The bony fragments were stabilized with a new rigid reconstruction plate. The tissue from the fibula was transferred to the site, and arterial and venous anastomoses were constructed with the use of an operating microscope (Fig. 5). Pathological examination of the excised tissue revealed no residual tumor. Dr. Dodson: Dr. Kaban, will you comment? Dr. Leonard B. Kaban (Oral and Maxillofacial Surgery): This very difficult case illustrates the many challenges clinicians encounter in managing primary jaw tumors of mesenchymal origin. These tumors can occur in both young and old persons and have a spectrum of clinical behavior that ranges from benign to locally aggressive to malignant. The histologic diagnoses include fibro-osseous lesions, atypical fibro-osseous lesions, aggressive fibromatoses, desmoplastic fibroma, myxoma, fibromyxoma, fibrosarcoma, and osteosarcoma. There are no Bone Graft and Titanium Reconstruction Plate.
Dr. David C. Harmon (Hematology–Oncology): In the absence of information from controlled trials to define the role of chemotherapy in this setting, the patient and I had extensive discussions and reviewed some of the available research concerning osteosarcoma of the jaw. Most reports indicated a high mortality rate, but recent reports of treatment involving radical resection seemed more optimistic. In a series at this institution, 5 a trend toward improved survival among patients who received chemotherapy was noted. A more recent, larger series from Memorial Sloan-Kettering Cancer Center 6 also suggested an improvement with the more aggressive, combined-treatment approach now in use. The few randomized trials of chemotherapy in osteosarcoma involved patients with large lesions in the arms or legs. Adjuvant chemotherapy substantially improves the cure rates in that high-risk setting. The toxicity, inconvenience, and expense of chemotherapy — close to a year of treatment with high-dose methotrexate, doxorubicin, cisplatin, and ifosfamide or similar drugs — are substantial. Nevertheless, even a 10 percent improvement in the cure rate would more than offset the small but real risk of death from chemotherapy. After consideration, this patient thought that chemotherapy was worth a try. Varvares performed immediate reconstruction with a vascularized, composite flap of bone and soft tissue from the fibula. The bony fragments were stabilized with a new rigid reconstruction plate. The tissue from the fibula was transferred to the site, and arterial and venous anastomoses were constructed with the use of an operating microscope (Fig. 5). Pathological examination of the excised tissue revealed no residual tumor. Dr. Dodson: Dr. Kaban, will you comment? Dr. Leonard B. Kaban (Oral and Maxillofacial Surgery): This very difficult case illustrates the many challenges clinicians encounter in managing primary jaw tumors of mesenchymal origin. These tumors can occur in both young and old persons and have a spectrum of clinical behavior that ranges from benign to locally aggressive to malignant. The histologic diagnoses include fibro-osseous lesions, atypical fibro-osseous lesions, aggressive fibromatoses, desmoplastic fibroma, myxoma, fibromyxoma, fibrosarcoma, and osteosarcoma. There are no Bone Graft and Titanium Reconstruction Plate.
Dr. David C. Harmon (Hematology–Oncology): In the absence of information from controlled trials to define the role of chemotherapy in this setting, the patient and I had extensive discussions and reviewed some of the available research concerning osteosarcoma of the jaw. Most reports indicated a high mortality rate, but recent reports of treatment involving radical resection seemed more optimistic. In a series at this institution, 5 a trend toward improved survival among patients who received chemotherapy was noted. A more recent, larger series from Memorial Sloan-Kettering Cancer Center 6 also suggested an improvement with the more aggressive, combined-treatment approach now in use. The few randomized trials of chemotherapy in osteosarcoma involved patients with large lesions in the arms or legs. Adjuvant chemotherapy substantially improves the cure rates in that high-risk setting. The toxicity, inconvenience, and expense of chemotherapy — close to a year of treatment with high-dose methotrexate, doxorubicin, cisplatin, and ifosfamide or similar drugs — are substantial. Nevertheless, even a 10 percent improvement in the cure rate would more than offset the small but real risk of death from chemotherapy. After consideration, this patient thought that chemotherapy was worth a try. Varvares performed immediate reconstruction with a vascularized, composite flap of bone and soft tissue from the fibula. The bony fragments were stabilized with a new rigid reconstruction plate. The tissue from the fibula was transferred to the site, and arterial and venous anastomoses were constructed with the use of an operating microscope (Fig. 5). Pathological examination of the excised tissue revealed no residual tumor. Dr. Dodson: Dr. Kaban, will you comment? Dr. Leonard B. Kaban (Oral and Maxillofacial Surgery): This very difficult case illustrates the many challenges clinicians encounter in managing primary jaw tumors of mesenchymal origin. These tumors can occur in both young and old persons and have a spectrum of clinical behavior that ranges from benign to locally aggressive to malignant. The histologic diagnoses include fibro-osseous lesions, atypical fibro-osseous lesions, aggressive fibromatoses, desmoplastic fibroma, myxoma, fibromyxoma, fibrosarcoma, and osteosarcoma. There are no Bone Graft and Titanium Reconstruction Plate.
Dr. David C. Harmon (Hematology–Oncology): In the absence of information from controlled trials to define the role of chemotherapy in this setting, the patient and I had extensive discussions and reviewed some of the available research concerning osteosarcoma of the jaw. Most reports indicated a high mortality rate, but recent reports of treatment involving radical resection seemed more optimistic. In a series at this institution, 5 a trend toward improved survival among patients who received chemotherapy was noted. A more recent, larger series from Memorial Sloan-Kettering Cancer Center 6 also suggested an improvement with the more aggressive, combined-treatment approach now in use. The few randomized trials of chemotherapy in osteosarcoma involved patients with large lesions in the arms or legs. Adjuvant chemotherapy substantially improves the cure rates in that high-risk setting. The toxicity, inconvenience, and expense of chemotherapy — close to a year of treatment with high-dose methotrexate, doxorubicin, cisplatin, and ifosfamide or similar drugs — are substantial. Nevertheless, even a 10 percent improvement in the cure rate would more than offset the small but real risk of death from chemotherapy. After consideration, this patient thought that chemotherapy was worth a try. Varvares performed immediate reconstruction with a vascularized, composite flap of bone and soft tissue from the fibula. The bony fragments were stabilized with a new rigid reconstruction plate. The tissue from the fibula was transferred to the site, and arterial and venous anastomoses were constructed with the use of an operating microscope (Fig. 5). Pathological examination of the excised tissue revealed no residual tumor. Dr. Dodson: Dr. Kaban, will you comment? Dr. Leonard B. Kaban (Oral and Maxillofacial Surgery): This very difficult case illustrates the many challenges clinicians encounter in managing primary jaw tumors of mesenchymal origin. These tumors can occur in both young and old persons and have a spectrum of clinical behavior that ranges from benign to locally aggressive to malignant. The histologic diagnoses include fibro-osseous lesions, atypical fibro-osseous lesions, aggressive fibromatoses, desmoplastic fibroma, myxoma, fibromyxoma, fibrosarcoma, and osteosarcoma. There are no Bone Graft and Titanium Reconstruction Plate.
Dr. David C. Harmon (Hematology–Oncology): In the absence of information from controlled trials to define the role of chemotherapy in this setting, the patient and I had extensive discussions and reviewed some of the available research concerning osteosarcoma of the jaw. Most reports indicated a high mortality rate, but recent reports of treatment involving radical resection seemed more optimistic. In a series at this institution, 5 a trend toward improved survival among patients who received chemotherapy was noted. A more recent, larger series from Memorial Sloan-Kettering Cancer Center 6 also suggested an improvement with the more aggressive, combined-treatment approach now in use. The few randomized trials of chemotherapy in osteosarcoma involved patients with large lesions in the arms or legs. Adjuvant chemotherapy substantially improves the cure rates in that high-risk setting. The toxicity, inconvenience, and expense of chemotherapy — close to a year of treatment with high-dose methotrexate, doxorubicin, cisplatin, and ifosfamide or similar drugs — are substantial. Nevertheless, even a 10 percent improvement in the cure rate would more than offset the small but real risk of death from chemotherapy. After consideration, this patient thought that chemotherapy was worth a try. Varvares performed immediate reconstruction with a vascularized, composite flap of bone and soft tissue from the fibula. The bony fragments were stabilized with a new rigid reconstruction plate. The tissue from the fibula was transferred to the site, and arterial and venous anastomoses were constructed with the use of an operating microscope (Fig. 5). Pathological examination of the excised tissue revealed no residual tumor. Dr. Dodson: Dr. Kaban, will you comment? Dr. Leonard B. Kaban (Oral and Maxillofacial Surgery): This very difficult case illustrates the many challenges clinicians encounter in managing primary jaw tumors of mesenchymal origin. These tumors can occur in both young and old persons and have a spectrum of clinical behavior that ranges from benign to locally aggressive to malignant. The histologic diagnoses include fibro-osseous lesions, atypical fibro-osseous lesions, aggressive fibromatoses, desmoplastic fibroma, myxoma, fibromyxoma, fibrosarcoma, and osteosarcoma. There are no Bone Graft and Titanium Reconstruction Plate.
