Recurrent Osteosarcoma
Approximately 50% of relapses occur within 18 months of therapy termination and only 5% of recurrences develop beyond 5 years.[1,2,3,4] In two large series, the incidence of recurrence by site was as follows: lung only (65%–80%), bone only (8%–10%), local recurrence only (4%–7%), and combined relapse (10%–15%).[4,5] Patients with recurrent osteosarcoma should be assessed for surgical resectability, as they may sometimes be cured with aggressive surgical resection with or without chemotherapy.[6,5,7,8,9,10] The ability to achieve a complete resection of recurrent disease is the most important prognostic factor at first relapse, with a 5-year survival rate of 20% to 45% following complete resection of metastatic pulmonary tumors and a 20% survival rate following complete resection of metastases at other sites.[4,5,10,11]
The role of systemic chemotherapy for the treatment of patients with recurrent osteosarcoma is not well defined. The selection of further systemic treatment depends on many factors, including the site of recurrence, the patient's previous primary treatment, and individual patient considerations. Ifosfamide alone with mesna uroprotection, or in combination with etoposide, has shown activity in as many as one-third of patients with recurrent osteosarcoma who have not previously received this drug.[12,13,14,15] Cyclophosphamide and etoposide have activity in recurrent osteosarcoma [16] as does the combination of gemcitabine and docetaxel.[17] Peripheral blood stem cell transplant utilizing high-dose chemotherapy does not appear to improve outcome. High-dose samarium-153-EDTMP coupled with peripheral blood stem cell support may provide significant pain palliation in patients with bone metastases.[18,19,20,21]
Lung Only Recurrence
Repeated resections of pulmonary recurrences can lead to extended disease control and possibly cure for some patients.[11,22] Survival for patients with unresectable metastatic disease is less than 5%.[5,23] Five-year event free survical (EFS) for patients who have complete surgical resection of all pulmonary metastases ranges from 20% to 45%.[4,5,10,11] Factors that suggest a better outcome include fewer pulmonary nodules, unilateral pulmonary metastases,[24] or longer intervals between primary tumor resection and metastases.[4,5,25] Resection of metastatic disease followed by observation alone results in low overall survival and disease-free survival. A high percentage of patients with pulmonary nodules identified in only one lung who underwent staged bilateral thoracotomy were found to have palpable nodules in both lungs that were not visualized on a computed tomography scan. This suggests that patients with unilateral nodules may benefit from bilateral exploration.[24]
Bone Metastases Only
Patients with osteosarcoma who develop bone metastases have a poor prognosis. In one large series, the 5-year EFS rate was 11%.[26] Patients with late solitary bone relapse have a 5-year EFS rate of approximately 30%.[26,27,28]
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