Management of osteosarcoma pulmonary metastases

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Although there has been considerable improvement in survival among children with osteosarcoma over the past 30 years, patients with metastatic disease fare very poorly. The best-case scenario for metastatic patients is a survival rate of 30% assuming complete resection of lung metastases without other disease. To achieve this optimal outcome, an aggressive surgical approach is recommended in which all metastatic disease is resected. This includes metastatic foci that are detected by imaging as well as those only identified by palpation at thoracotomy. Investigation into the biology of the metastatic process of osteosarcoma as well as in identification of molecular features that correlate with prognosis is very active and will likely yield important findings that will impact therapy in the future. An area of investigation that remains needed is the prospective evaluation of the surgical management of these patients with the goal of critically evaluating the impact of the various surgical strategies on patient outcome measures, such as disease-recurrence and survival.

Section snippets

Imaging

An integral part of the management of osteosarcoma pulmonary metastases is the ability to image such disease with radiologic studies. The current radiographic “gold standard” for identification and localization of metastatic OS is helical computed tomography (CT) scanning.4 Although the speed and quality of resolution continue to improve, current CT scanning may miss small metastases (particularly those ≤5 mm in diameter).10, 11 The sensitivity of helical CT scanning is around 80% for all types

Prognostic characteristics

It is important to understand the impact of multiple patient and tumor characteristics on prognosis in children presenting with pulmonary metastases from osteosarcoma. The majority of retrospective case series that have addressed this question have found that number of metastases, disease-free interval from diagnosis to presentation of metastases, ability to completely resect the nodules, and the percentage “tumor necrosis” of the primary tumor after induction chemotherapy are the primary

Biology of metastases

It would obviously be preferable to prevent pulmonary metastases rather than be forced to surgically remove these lesions once identified. A hindrance in the development of effective therapies to decrease the occurrence of metastatic disease is an incomplete understanding of the biology of the metastatic process. Although an exhaustive review of the investigation into the biology of osteosarcoma is beyond the scope of this article, the practicing pediatric surgeon should be aware of the types

Surgical management issues

Although resection of osteosarcoma pulmonary metastases is a relatively uncommon procedure within the broad scope of pediatric surgical practice, there is no uniformity of surgical opinion on how to manage these patients beyond the belief that an aggressive approach is warranted and that without resection essentially all patients will succumb to their disease. We recently reviewed the M.D. Anderson Cancer Center experience with a focus on an aggressive approach to pulmonary resection. Although

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