Journal of Clinical Oncology, Vol 12, 1849-1858, Copyright © 1994 by American Society of Clinical Oncology
Pulmonary metastases of stage IIB extremity osteosarcoma and subsequent pulmonary metastases
WG Ward, K Mikaelian, F Dorey, JM Mirra, A Sassoon, EC Holmes, FR Eilber and JJ Eckardt
Department of Orthopaedic Surgery, Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, NC 27157-1070.
PURPOSE: This study investigated prognostic factors in nonmetastatic
high-grade extremity osteosarcoma and the prognosis following resection of
subsequent pulmonary metastases, with emphasis on the effect of
chemotherapy-induced tumor necrosis. PATIENTS AND METHODS: We reviewed 111
consecutive patients with high-grade nonmetastatic extremity osteosarcoma
treated with preoperative chemotherapy and surgical resection, with
additional review of 36 patients who had subsequent pulmonary metastases
resected. RESULTS: The overall 5-year survival rate was 53%. In resected
primary tumors, tumor-free resection margin (P < .001) and increasing
chemotherapy-induced tumor necrosis (> 90% threshold, P < .003)
correlated with increased metastasis-free survival. Relative risk factors
for metastases were as follows: tumor- containing resection margin (most
likely to metastasize); poor response to preoperative chemotherapy and/or
lack of postoperative chemotherapy (next worse prognosis); and excellent
response to preoperative chemotherapy (> or = 90% necrosis) combined
with postoperative chemotherapy (best prognosis). The 5-year survival rate
following pulmonary metastasis resection was 23%, whereas a 0% 4-year
survival rate followed development of bony metastases (P < .001). The
extent of tumor necrosis in resected pulmonary metastases did not affect
prognosis. Survival was best in patients with three or fewer pulmonary
nodules (P < .048), four or fewer recurrent pulmonary nodules (P <
.047), unilateral pulmonary metastases (P < .037), or longer intervals
between primary tumor resection and metastases (P < .082). CONCLUSION:
Intensive preoperative and postoperative chemotherapy combined with
complete resection of both primary and metastatic pulmonary osteosarcomas
is justified, with a goal of 100% tumor necrosis and excision. Although
current treatment regimens allow effective salvage therapy for a few
patients with pulmonary metastases, more effective systemic treatment is
needed.
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