Osteosarcoma surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Suveenkrishna Pothuru, M.B,B.S. [2]

Overview

The mainstay of therapy for osteosarcoma is surgical resection. Rather than using the standard staging system, a simpler system is often used when planning treatment for osteosarcoma. This system divides osteosarcomas into 2 groups: localized osteosarcoma and metastatic osteosarcoma.

Surgery

• Current standard treatment for osteosarcoma is to use neoadjuvant chemotherapy (chemotherapy given before surgery) followed by surgical resection.
• If a limb-salvage procedure is feasible, a course of multi-drug chemotherapy precedes surgery to downstage the tumor, followed by wide resection of the bone and insertion of an endoprosthesis.
• The outcome depend on different factors such as age, sex, site, size, and type but the most important predictor is the histologic degree of necrosis post induction chemotherapy; 90% histologic necrosis is associated with much better prognosis.
• Although about 90% of patients are able to have limb-salvage surgery, complications, such as infection, prosthetic loosening and non-union, or local tumor recurrence may cause the need for further surgery or amputation.
• Rather than using the standard staging system, a simpler system is often used when planning treatment for osteosarcoma. This system divides osteosarcomas into 2 groups: localized osteosarcoma and metastatic osteosarcoma.

Localized Osteosarcoma

• The cancer is only in the bone where it started and may be in the tissues next to the bone.
• Localized osteosarcomas are further divided into 2 groups: localized resectable osteosarcoma and localized unresectable osteosarcoma.

Localized resectable osteosarcoma

Resectable tumors are those in which all the visible tumor can be removed by surgery and the cancer has not spread to other parts of the body.

• Surgery is the primary treatment for localized resectable osteosarcoma.
• Surgery is usually the only treatment used for low-grade, localized resectable osteosarcomas (chemotherapy is not given).
• The types of surgery done include:
  • Limb-sparing surgery
  • Amputation
  • Reconstruction
  • Rotationplasty
• Chemotherapy may be offered for localized resectable osteosarcoma.
• It is usually given before surgery.
• Chemotherapy is also given after surgery to destroy any remaining cancer cells.

Localized unresectable osteosarcoma

Localized unresectable tumors have not spread to other parts of the body, but they cannot be completely removed by surgery. They may be too large or too close to vital structures in the body to be resected.

• Chemotherapy is usually the first treatment offered for localized unresectable osteosarcoma.
• If the tumour shrinks enough to become resectable, it is then treated with surgery.
• If the osteosarcoma is still unresectable after chemotherapy, radiation therapy may be given to control pain.

Metastatic Osteosarcoma

Metastatic osteosarcoma has already spread to distant parts of the body at the time of diagnosis. It usually spreads to the lungs.

Lung Metastasis

• Treatment of osteosarcoma with lung metastasis may include Combination chemotherapy followed by surgery to remove the primary cancer and the cancer that has spread to the lung.

Bone metastasis or bone with lung metastasis

• Osteosarcoma spread to a distant bone and/or the lung.
• Treatment may include Combination chemotherapy followed by surgery to remove the primary tumor and the cancer that has spread to other parts of the body.
• More chemotherapy is given after surgery.
• If some tumors remain unresectable after chemotherapy, radiation therapy may be given to control pain.

Recurrent osteosarcoma

Recurrent osteosarcoma means that the bone cancer has come back (has recurred) after it was treated. In rare cases, it may recur in the same location as the original cancer (local recurrence). Usually it recurs in the lungs. Treatment of recurrent osteosarcoma of the bone may include the following:

• Surgery to remove the tumor with or without chemotherapy.
• If the cancer recurs in the same location on an arm or leg after limb-sparing surgery, amputation of the limb may be recommended.

• Chemotherapy may be offered for recurrent osteosarcoma to control the growth of the tumor.
• Radiation therapy may be offered to help relieve symptoms.
• Samarium with or without stem cell transplant using the patient's own stem cells, as palliative treatment to relieve pain and improve the quality of life.