Treatment for Osteosarcoma Recurrence in Adulthood
Treatment for recurrent osteosarcoma in adults is primarily surgical, with complete removal of all metastases as the cornerstone of therapy, as the disease is otherwise almost universally fatal. 1
Surgical Management
- Complete surgical resection of all detectable disease is mandatory 1
- For pulmonary metastases: Bilateral exploration by open thoracotomy including palpation of both lungs is recommended 1
- CT scans tend to underestimate the number of pulmonary metastases and may fail to detect contralateral involvement 1
- Even patients with multiple recurrences may be cured as long as recurrences are resectable 1
- Repeated thoracotomies are often warranted for subsequent recurrences 1
Chemotherapy Options
The role of second-line chemotherapy is less well defined than surgery, with no accepted standard regimen 1. Options include:
- Ifosfamide-based regimens
- Etoposide
- Carboplatin
- High-dose methotrexate + doxorubicin
- Cisplatin + doxorubicin
- High-dose methotrexate + cisplatin
- Ifosfamide + cisplatin 1
Second-line chemotherapy has shown limited prolongation of survival in patients with inoperable metastatic recurrences 1. For operable disease, the benefit is less clear, with positive correlation observed in only one of two large studies 1.
Radiotherapy
- Indicated for inoperable tumors or for palliation 1
- Options include high-dose (55-70 Gy) photon or neutron therapy 1
- May be associated with limited prolongation of survival in inoperable cases 1
Prognostic Factors
Several factors are associated with improved disease-free and overall survival 2:
- Unilateral pulmonary recurrence
- Solitary pulmonary nodule at recurrence
- More than 24 months between initial diagnosis and first recurrence
- Achievement of a second complete remission
Monitoring and Follow-up
Follow-up should include 1:
- Every 6 weeks to 3 months in years 1-2 after diagnosis
- Every 2-4 months in years 3-4
- Every 6 months in years 5-10
- Every 6-12 months thereafter
Each visit should include:
- History and physical examination
- Chest X-ray
- X-rays of the primary tumor site (recommended every 4 months until the end of year 4)
Important Considerations
- Prognosis is poor, with long-term post-relapse survival in <20% of patients 1
- More than one-third of patients who achieve a second surgical remission survive >5 years 1
- Late metastases may occur >10 years after diagnosis 1
- Multimodal therapy may cause permanent alterations of cardiac, renal, auditory and reproductive function 1
- For patients with isolated pulmonary recurrence, 4-year disease-free survival is approximately 7% and overall survival is 28% 2
The treatment approach should be aggressive when feasible, as surgical resection offers the best chance for long-term survival even with multiple recurrences, while recognizing the overall poor prognosis of recurrent disease.