1. No category

This practice algorithm has been specifically developed for M. D. Anderson using a multidisciplinary approach and taking into consideration circumstances particular to M. D. Anderson,
including the following: M. D. Anderson’s specific patient population; M. D. Anderson’s services and structure; and M. D. Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.
Note:
Consider Clinical Trials as treatment options for eligible patients.
Refer to a center with both pediatric oncology and orthopedic surgery is essential.
CLINICAL EVALUATION
History and Physical
CBC, differential,
platelets, total protein,
albumin, calcium,
total bilirubin,
alkaline Phosphatase,
LDH, AST, Phosphate,
sodium, potassium,
chloride, CO2, and
coagulation battery.
Plain films of primary
MRI of primary
Bone Scan
CXR
CT Scan of chest
PET scan
Biopsy (open vs. needle)
Histology review by
Bone Tumor Pathologist
EKG or ECHO
CVC
Pregnancy Test if
clinically indicated
Discuss fertility
*Excluding Head and Neck and Low Grade Osteosarcoma
ADJUVANT TREATMENT
PRIMARY TREATMENT
See page 2
Yes
Consider local
treatment options for
Primary disease
Yes
High Dose Ifosfamide
for 4-8 cycles2
Surgery
(amputation)3
Yes
Metastasis?
Pulmonary
Metastasis?
No
Is Primary
Tumor
resectable?
Yes
Is there a
treatment
response?
Repeat
CT of
chest
Yes
Assess Treatment
Response Reimage and
clinical exam of
Primary Tumor
High Dose
Ifosfamide
for 4-8
cycles2
No
No
Neoadjuvant
Chemotherapy1 for
5-6 weeks
Progressive
disease of
Primary site?
No
Is Primary
Tumor
resectable?
Resume
Neoadjuvant
Chemotherapy
for 5 – 6 weeks
Yes
Surgery:
(limb salvage
vs.
amputation)
Pathological
response?
No
Consider individualized
surveillance treatment
regimen based on
clinical indications
Local palliative treatment
for Primary Tumor and
● Consider management of
metastatic disease
●
No
Greater
than or
equal to
90%
Necrosis
Adjuvant
Chemotherapy 2-4
weeks after surgery
for approximately
27-31 weeks4
Less than
90%
Necrosis
Continue Adjuvant
Chemotherapy
and consider
Ifosfamide5
See page 2 for management
based on metastatic disease
1
DOXOrubicin plus CISplatin, High-Dose MethoTREXate plus Dexrazoxane for cardioprotection
2
High-dose Ifosfamide /Mesna plus or minus Etoposide; monitor and take into consideration renal function for continuation of chemotherapy regimen
4
DOXOrubicin + CISplatin, High-dose MethoTREXate with or without Ifosfamide plus or minus Etoposide (MAPIE) plus Dexrazoxane for cardioprotection
Copyright 2012 The University of Texas M.D. Anderson Cancer Center
SURVEILLANCE
3
5
Consider amputation, especially if an extremity lesion
High-dose Ifosfamide /Mesna plus or minus Etoposide
See page 3 for
Surveillance
Department of Clinical Effectiveness V2
Department
ClinicalStaff
Effectiveness
Approved by Executive Committee
of theofMedical
03/27/2012V2
Approved by Executive Committee of the Medical Staff 03/27/2012
This practice algorithm has been specifically developed for M. D. Anderson using a multidisciplinary approach and taking into consideration circumstances particular to M. D. Anderson,
including the following: M. D. Anderson’s specific patient population; M. D. Anderson’s services and structure; and M. D. Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.
Note:
Consider Clinical Trials as treatment options for eligible patients.
Refer to a center with both pediatric oncology and orthopedic surgery is essential.
*Excluding Head and Neck and Low Grade Osteosarcoma
SURVEILLANCE
ADJUVANT TREATMENT
PRIMARY TREATMENT
Metastasis
Consider individualized
treatment based on clinical
indications
● Palliative Care
● Consider Supportive Care
●
Yes
DOXOrubicin,
CISplatin,
High dose
MethoTREXate
for 4-6 weeks6
Restage to
assess for
progression
Is there tumor
progression?
No
Continue same
Chemotherapy for
6 to 8 weeks
Re-image
Primary and
Metastasis
Is there tumor
progression?
No
Yes
Yes
● Local control of
32
Is there a
plateau of
response?
Yes
No
6
7
DOXOrubicin + CISplatin, High-Dose MethoTREXate plus Dexrazoxane for cardioprotection
Primary Tumor
● Continue
chemotherapy
● Consider local
therapies of other
disease sites
Continue same
chemotherapy
for 6 to 8 weeks
Reassess
for
treatment
response
Is there disease
progression?
No
See pg 3 for
Surveillance
Consider local therapies of all sites
7
● Monitor for treatment response
●
Monitor for progression after 2-3 months of chemotherapy for approximately one year of treatment. If no progression of
disease following completion of chemotherapy regimen then move patient to surveillance (page 3).
Copyright 2012 The University of Texas M.D. Anderson Cancer Center
Department of Clinical Effectiveness V2
Department
ClinicalStaff
Effectiveness
Approved by Executive Committee
of theofMedical
03/27/2012V2
Approved by Executive Committee of the Medical Staff 03/27/2012
This practice algorithm has been specifically developed for M. D. Anderson using a multidisciplinary approach and taking into consideration circumstances particular to M. D. Anderson,
including the following: M. D. Anderson’s specific patient population; M. D. Anderson’s services and structure; and M. D. Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.
Note:
Consider Clinical Trials as treatment options for eligible patients.
Refer to a center with both pediatric oncology and orthopedic surgery is essential.
Copyright 2012 The University of Texas M.D. Anderson Cancer Center
*Excluding Head and Neck and Low Grade Osteosarcoma
Department of Clinical Effectiveness V2
Department
ClinicalStaff
Effectiveness
Approved by Executive Committee
of theofMedical
03/27/2012V2
Approved by Executive Committee of the Medical Staff 03/27/2012
This practice algorithm has been specifically developed for M. D. Anderson using a multidisciplinary approach and taking into consideration circumstances particular to M. D. Anderson,
including the following: M. D. Anderson’s specific patient population; M. D. Anderson’s services and structure; and M. D. Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.
Note:
Consider Clinical Trials as treatment options for eligible patients.
Refer to a center with both pediatric oncology and orthopedic surgery is essential.
*Excluding Head and Neck and Low Grade Osteosarcoma
SUGGESTED READINGS
1. Children’s Oncology Group Protocols: CCG7921 and COG AOST 0331
2. Anderson PM and Salazar-Abshire M. Improving outcomes in difficult bone cancers using multimodality therapy including radiation: physician and nursing
perspectives. Current Oncology 8:415-422, 2006.
3. Anderson P, Aguilera D, Pearson M, WooS. Outpatient chemotherapy plus radiotherapy in sarcomas: improving cancer control with radiosensitizing agents.
Cancer Control 15;38-46, 2008. PMID: 18094659
4. Mahajan A, Woo S, Kornguth DG, Hughes D, Huh W, Chang EL, Herzog CE, Peloski CE, Anderson PM. Multimodality treatment of osteosarcoma: Radiation
in a high-risk cohort. Pediatric Blood and Cancer. 50:976-982, 2008. PMID: 18213710.
5. Anderson P, Kornguth D, Ahrar K, Hughes D, Phan P, Huh W, Cornelius, K, Mahajan A. Recurrent, refractory, metastatic, and/or unresectable pediatric
sarcomas: treatment options for young people that are off the roadmap. Pediatric Health 2:605-615, 2008.
6. Hamayun Imran, Felicity Enders, Mark Krailo, Franklin Sim, Scott Okuno, Douglas Hawkins, Joseph Neglia, R. Lor Randall, Richard Womer, Leo
Mascarenhas, and Carola A.S. Arndt Effect of Time to Resumption of Chemotherapy After Definitive Surgery on Prognosis for Non-Metastatic Osteosarcoma
J. Bone Joint Surg. Am., Mar 2009; 91: 604 - 612.
Copyright 2012 The University of Texas M.D. Anderson Cancer Center
Department of Clinical Effectiveness V2
Department
ClinicalStaff
Effectiveness
Approved by Executive Committee
of theofMedical
03/27/2012V2
Approved by Executive Committee of the Medical Staff 03/27/2012
This practice algorithm has been specifically developed for M. D. Anderson using a multidisciplinary approach and taking into consideration circumstances particular to M. D. Anderson,
including the following: M. D. Anderson’s specific patient population; M. D. Anderson’s services and structure; and M. D. Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.
Note:
Consider Clinical Trials as treatment options for eligible patients.
Refer to a center with both pediatric oncology and orthopedic surgery is essential.
*Excluding Head and Neck and Low Grade Osteosarcoma
DEVELOPMENT CREDITS
Pete Anderson, M.D., Ph.D. Ŧ
Valerae Lewis, M.D. Ŧ
Anita Mahajan, M.D. Ŧ
Dennis Hughes, M.D., Ph.D.
Janie Rutledge, RN, MS, ANP, OCN
Stephanie Fulton, MS
Bryan Moon, M.D.
Mary McAleer, M.D., Ph.D.
Shiao Woo, M.D.
Patrick Lin, M.D.
Eugenie Kleinerman, M.D.
Ŧ Core Development Team
Copyright 2012 The University of Texas M.D. Anderson Cancer Center
Department of Clinical Effectiveness V2
Department
ClinicalStaff
Effectiveness
Approved by Executive Committee
of theofMedical
03/27/2012V2
Approved by Executive Committee of the Medical Staff 03/27/2012