Resection of Pulmonary Metastases in Osteosarcoma. Is it Justified?

Abstract

Osteosarcoma shows a high propensity to metastasize to the lung. Pulmonary metastases occur in approximately 40% of patients with osteosarcoma during the course of their disease, and the lung is the only site of metastatic disease in the majority of these cases. Chemotherapy continues to be the standard treatment for metastatic sarcoma, but when it is the only treatment modality, it still results in poor survival rates. In order to improve the outcome, a combination of chemotherapy followed by surgical resection of the metastases has been advocated for selected cases. Substantial evidence documents the potential benefit of pulmonary metastasectomy in osteosarcoma, resulting, in various series, in a 5-year overall survival of 30-40%. Aggressive surgery in combination with chemotherapy appears to be justified for metastatic osteosarcoma in selected patients, and it is associated with acceptable morbidity. Synchronous metastases, a short interval from diagnosis to presentation of pulmonary metastasis, a higher number (>4) of metastases, bilateral and central location, pleural infiltration, poor response to preoperative chemotherapy and concurrent (resectable) extra-pulmonary disease have all been associated with a less favorable outcome. Complete surgical resection is essential for giving a chance of long-term survival. Lateral thoracotomy with salvage of as much lung parenchyma as possible is the procedure of choice. Repeat surgery for re-recurrences is feasible and beneficial, resulting in prolonged survival in a number of cases.