Pretreatment factors that influence outcome include site and size of the primary tumor and presence or absence of clinically detectable metastatic disease. After administration of preoperative chemotherapy, surgical resectability and the degree of tumor necrosis influence outcome. In general, prognostic factors in osteosarcoma have not been helpful in identifying patients who might benefit from treatment intensification or who might require less therapy while maintaining an excellent outcome.
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The site of the primary tumor is a significant prognostic factor for patients with localized disease. Among extremity tumors, distal sites have a more favorable prognosis than proximal sites. Axial skeleton primary tumors are associated with the greatest risk of progression and death, primarily related to the inability to achieve a complete surgical resection. Pelvic osteosarcomas make up 7% to 9% of all osteosarcomas; survival rates for patients with pelvic primary tumors are 20% to 47%.[2,3] Complete surgical resection is associated with positive outcome for osteosarcoma of the pelvis. Within the craniofacial osteosarcoma group, patients with mandibular tumors have a significantly better prognosis than patients with extragnathic tumors. For patients with osteosarcoma of craniofacial bones, complete resection of the primary tumor with negative margins is essential for cure.[5,6,7] Despite a relatively high rate of inferior necrosis following neoadjuvant chemotherapy, fewer patients with craniofacial primaries develop systemic metastases than do patients with osteosarcoma originating in the extremities.[8,9,10] This low rate of metastasis may be related to the relatively smaller size and higher incidence of lower grade tumors in osteosarcoma of the head and neck. There is a better prognosis for patients who have osteosarcoma of the head and neck than for those who have appendicular lesions when treated with surgery alone. While small series have not shown a benefit from adjuvant chemotherapy for patients with osteosarcoma of the head and neck, one meta-analysis concluded that systemic chemotherapy improves the prognosis for these patients. Another large meta-analysis detected no benefit from chemotherapy for patients with osteosarcoma of the head and neck, but suggested that the incorporation of chemotherapy into treatment of patients with high-grade tumors may improve survival. A retrospective analysis identified a trend toward better survival in patients with high-grade osteosarcoma of the mandible and maxilla who received adjuvant chemotherapy.[7,11] Radiation therapy was found to improve local control, disease-specific survival, and overall survival (OS) in a retrospective study of osteosarcoma of the craniofacial bones, which had positive or uncertain resection margins after surgical resection.[Level of evidence: 3iiA] Radiation-associated craniofacial osteosarcomas are generally high-grade lesions, usually fibroblastic, that tend to recur locally with a high rate of metastasis. In the German series, approximately 25% of patients with craniofacial osteosarcoma had osteosarcoma as a second tumor and 11 patients were postretinoblastoma. In this series, there was no difference in outcome for primary or secondary craniofacial osteosarcoma.