Effect of concurrent metastatic disease on survival in children and adolescents undergoing lung resection for metastatic osteosarcoma

A 20-year retrospective analysis of CT-based pre-operative identification of pulmonary metastases in patients with osteosarcoma: A single-center review

“…However, despite its higher level of sensitivity, multiple studies have shown that CT is not adequate for enumerating OS lung metastases [26, 30, 31]. Given the abundance of trials showing that complete metastasectomy is the single most important determinant of survival after pulmonary relapse [2, 7-20], we hypothesized that this lack of sensitivity would lead to unresected metastases if the surgeon limited his/her resections to lesions seen on CT.…”

“…This study, unfortunately, cannot address the most controversial question in metastatic OS‒ specifically, whether these missed metastases at operation affect disease-free or overall survival. While numerous published analyses have raised concerns about the sensitivity of CT in metastatic OS [26, 29-31], and have emphasized the importance of complete resection in long-term outcome in OS [2, 7-17, 19, 20], there have been no studies analyzing the effect of surgical approach on overall survival. Recently, some studies have supported the possibility of minimally invasive techniques in highly selected populations [33] and questioned the need for contralateral thoracotomy with a negative contralateral CT [34]; however, they are limited by small numbers and highly selected populations.…”

“…Unfortunately, survival is drastically lower in patients with relapsed OS [2, 3], 75% of whom relapse with metastases in the lungs [4, 5]. Over the last four decades, significant progress has been made in the treatment of pulmonary metastases in OS, bringing the overall survival from 0% in 1970 [6] to 17-34% in the most recent published series [7-11]. Prognosis in patients with pulmonary metastases has repeatedly been shown to depend on the extent of treatment-induced necrosis in the lesions, disease-free interval before relapse, the total number of metastases, and unilateral versus bilateral involvement.…”

“…Prognosis in patients with pulmonary metastases has repeatedly been shown to depend on the extent of treatment-induced necrosis in the lesions, disease-free interval before relapse, the total number of metastases, and unilateral versus bilateral involvement. The single most important prognostic factor, however, is the ability to achieve complete resection of the metastases, with little or no benefit derived from systemic therapy [2, 7-20]. …”

Surgical treatment of pulmonary metastases in pediatric solid tumors

“…Good prognostic factors in metastatic osteosarcoma include diagnosis of metastasis after treatment rather than prior to or during chemotherapy, longer disease-free interval between treatment and relapse, fewer metastatic lesions, better histologic response to preoperative chemotherapy, and the ability to clear all metastatic disease surgically. Extra-pulmonary metastasis and metastasis associated with local relapse are associated with a dismal prognosis, with long-term survival of less than 10%, and while chemotherapy at relapse may yield some prolongation of survival, it does not change overall survival 27, 28, 31–33, 38, 40–43 . However, repeat thoracotomy for subsequent lung-only relapses has been shown to afford some chance of cure if complete resection is possible 40, 44, 45 .…”