APSA Paper
Long-term survival after aggressive resection of pulmonary metastases among children and adolescents with osteosarcoma☆

https://doi.org/10.1016/j.jpedsurg.2005.10.089Get rights and content

Abstract

Purpose

Although survival without resection of pulmonary metastases from osteosarcoma is unlikely, not all surgeons agree on an aggressive surgical approach. We have taken an approach to attempt surgical resection if at all feasible regardless of number of metastases and disease-free interval (DFI). This study presents information on long-term follow-up after this aggressive approach to resection.

Methods

A single-institution retrospective cohort study of osteosarcoma patients younger than 21 years with pulmonary metastases, limited to the contemporary chemotherapeutic period (1980-2000), was conducted.

Results

In 137 patients, synchronous (23.4%) or metachronous (76.6%) pulmonary nodules were identified. The median follow-up was 2.0 years (5 days to 20.1 years) for all patients. Overall survival among patients who had pulmonary nodules was 40.2% and 22.6% at 3 and 5 years, respectively. Ninety-nine patients underwent attempted pulmonary metastasectomy (mean survival, 33.6 months; 95% confidence interval, 25.1-42.1) and 38 patients did not (mean survival, 10.1 months; 95% confidence interval, 6.5-13.6; P < .001, t test). Characteristics that were associated with an increased likelihood of 5-year overall survival after pulmonary resection were primary tumor necrosis greater than 98% after neoadjuvant chemotherapy (P < .05) and DFI before developing lung metastases more than 1 year (P < .001). No statistically significant difference in overall survival or disease-free survival was found based on the number of pulmonary metastases resected. Characteristics including primary tumor size, site, or extension; chemotherapy; early vs late metastases; unilateral vs bilateral metastases; and resection margins did not significantly affect survival.

Conclusions

Most patient and tumor characteristics commonly used by surgeons to determine utility of resection of pulmonary metastases among patients with osteosarcoma are not associated with outcome. Biology of the particular tumor (response to preoperative chemotherapy, measured by tumor necrosis percentage, and DFI), as opposed to tumor burden, appears to influence survival more significantly. We would advocate considering repeat pulmonary resection for patients with recurrent metastases from osteosarcoma.

Section snippets

Materials and methods

After obtaining institutional review board approval, a comprehensive search of the Tumor Registry database at the University of Texas MD Anderson Cancer Center was used to identify patients younger than 21 years with osteosarcoma metastatic to the lung. Patients with primary tumors of the head and neck, radiotherapy-induced osteosarcoma, or initial diagnosis and majority of treatment (defined as preoperative through postoperative chemotherapy) at outside institutions were excluded. Patients

Results

There were 272 patients with osteosarcoma of the trunk or extremities who were younger than 21 years and who had medical records available for review. Of these, 137 developed or presented with radiographically evident (on lung tomograms, chest x-ray, or computed tomographic scan) pulmonary nodules. These 137 patients formed the initial study cohort.

The median follow-up for the initial cohort was 2.5 years (5 days to 20.1 years). Overall survival at 3 and 5 years was 40.2% and 22.6%,

Discussion

Just 3 decades ago, the development of pulmonary metastases from osteosarcoma virtually ensured an early death [3], [17]. Advances in chemotherapeutic strategy and refinement of surgical indications and approaches have significantly improved the prognosis for these patients.

Two independent factors that were shown to predict long-term survival after pulmonary metastasectomy were the response of the primary tumor to preoperative chemotherapy and DFI. Primary tumor response to chemotherapy (or

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    Presented at the 36th Annual Meeting of the American Pediatric Surgical Association, Phoenix, AZ, May 29-June 1, 2005.

    ☆

    This study was supported in part by grants K23HD001473 and K24RR17050 from the National Institutes of Health, Bethesda, Md.

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