Osteosarcoma natural history, complications and prognosis
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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
Common complications of osteosarcoma include pathologic fracture and metastasis. Pretreatment factors that influence outcome of the osteosarcoma are primary tumor site, size of the primary tumor, and site of metastasis. After administration of preoperative chemotherapy, factors that influence outcome of the osteosarcoma are adequacy of tumor resection and necrosis following induction or neoadjuvant chemotherapy. The 5 year survival rate of osteosarcoma after adequate therapy is approximately 60-80%.
Complications
- The most frequent complications of osteosarcoma are pathologic fracture and the development of metastatic disease.
- Most common sites of metastasis are the bone, lung, and regional lymph nodes.
- Radiologic evidence of metastatic tumor deposits in the lungs, other bones, or other distant sites is found in approximately 20% of patients at diagnosis, with 85% to 90% of metastatic disease presenting in the lungs.
Prognosis
The 5-year survival rate of osteosarcoma after adequate therapy is approximately 60-80%. Pretreatment factors that influence outcome of the osteosarcoma include the following:[1]
Primary tumor site
Pelvis
- Survival rates for patients with pelvic primary tumors are 20% to 47%.
- Complete surgical resection is associated with positive outcome for osteosarcoma of the pelvis.
Craniofacial/head and neck
- In patients with craniofacial osteosarcoma, those with mandibular tumors have a significantly better prognosis than do patients with extragnathic tumors.
Extraskeletal
- With current combined-modality therapy, the outcome for patients with extraskeletal osteosarcoma appears to be similar to that for patients with primary tumors of bone.
Size of the primary tumor
- Larger tumors have a worse prognosis than smaller tumors.
- Tumor size has been assessed by the longest single dimension, by the cross-sectional area, or by an estimate of tumor volume. All have correlated with outcome.
- Serum lactate dehydrogenase (LDH), which also correlates with outcome, is a likely surrogate for tumor volume.
Metastatic disease
Patients with localized disease have a much better prognosis than do patients with overt metastatic disease. As many as 20% of patients will have radiographically detectable metastases at diagnosis, with the lung being the most common site. The prognosis for patients with metastatic disease appears to be determined largely by the site, the number of metastases, and the surgical resectability of the metastatic disease:
Site of metastases
- Prognosis appears more favorable for patients with fewer pulmonary nodules and for those with unilateral rather than bilateral pulmonary metastases.
Number of metastases
- Patients with skip metastases (at least two discontinuous lesions in the same bone) have been reported to have poor prognosis.
- Skip metastasis in a bone other than the primary bone should be considered systemic metastasis.
- Patients with multifocal osteosarcoma (defined as multiple bone lesions without a clear primary tumor) have an extremely poor prognosis.
Age
- Younger people with osteosarcoma may have a more favorable prognosis.
After administration of preoperative chemotherapy, factors that influence outcome include the following:[2]
Adequacy of tumor resection
- Resectability of the tumor is a critical prognostic feature because osteosarcoma is relatively resistant to radiation therapy.
- Complete resection of the primary tumor and any skip lesions with adequate margins is generally considered essential for cure.
- A retrospective review of patients with craniofacial osteosarcoma performed by the German-Austrian-Swiss osteosarcoma cooperative group reported that incomplete surgical resection was associated with inferior survival probability.
Necrosis following induction or neoadjuvant chemotherapy
- Most treatment protocols for osteosarcoma use an initial period of systemic chemotherapy before definitive resection of the primary tumor (or resection of sites of metastases).
- The pathologist assesses necrosis in the resected tumor.
- Patients with at least 90% necrosis in the primary tumor after induction chemotherapy have a better prognosis than those with less necrosis.
- Patients with less necrosis (<90%) in the primary tumor following initial chemotherapy have a higher rate of recurrence within the first 2 years compared with patients with a more favorable amount of necrosis (≥90%).
- Less necrosis should not be interpreted to mean that chemotherapy has been ineffective; cure rates for patients with little or no necrosis following induction chemotherapy are much higher than cure rates for patients who receive no chemotherapy.
References
- ↑ Osteosarcoma. National cancer institute. http://www.cancer.gov/types/bone/hp/osteosarcoma-treatment-pdq
- ↑ Osteosarcoma. National cancer institute. http://www.cancer.gov/types/bone/hp/osteosarcoma-treatment-pdq