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Long-term survival after aggressive resection of pulmonary metastases among children and adolescents with osteosarcoma

Department of Surgery, University of Texas Medical Sciences Center, Houston, TX 77030, USA.
Journal of Pediatric Surgery (Impact Factor: 1.31). 02/2006; 41(1):194-9. DOI: 10.1016/j.jpedsurg.2005.10.089
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ABSTRACT Although survival without resection of pulmonary metastases from osteosarcoma is unlikely, not all surgeons agree on an aggressive surgical approach. We have taken an approach to attempt surgical resection if at all feasible regardless of number of metastases and disease-free interval (DFI). This study presents information on long-term follow-up after this aggressive approach to resection.
A single-institution retrospective cohort study of osteosarcoma patients younger than 21 years with pulmonary metastases, limited to the contemporary chemotherapeutic period (1980-2000), was conducted.
In 137 patients, synchronous (23.4%) or metachronous (76.6%) pulmonary nodules were identified. The median follow-up was 2.0 years (5 days to 20.1 years) for all patients. Overall survival among patients who had pulmonary nodules was 40.2% and 22.6% at 3 and 5 years, respectively. Ninety-nine patients underwent attempted pulmonary metastasectomy (mean survival, 33.6 months; 95% confidence interval, 25.1-42.1) and 38 patients did not (mean survival, 10.1 months; 95% confidence interval, 6.5-13.6; P < .001, t test). Characteristics that were associated with an increased likelihood of 5-year overall survival after pulmonary resection were primary tumor necrosis greater than 98% after neoadjuvant chemotherapy (P < .05) and DFI before developing lung metastases more than 1 year (P < .001). No statistically significant difference in overall survival or disease-free survival was found based on the number of pulmonary metastases resected. Characteristics including primary tumor size, site, or extension; chemotherapy; early vs late metastases; unilateral vs bilateral metastases; and resection margins did not significantly affect survival.
Most patient and tumor characteristics commonly used by surgeons to determine utility of resection of pulmonary metastases among patients with osteosarcoma are not associated with outcome. Biology of the particular tumor (response to preoperative chemotherapy, measured by tumor necrosis percentage, and DFI), as opposed to tumor burden, appears to influence survival more significantly. We would advocate considering repeat pulmonary resection for patients with recurrent metastases from osteosarcoma.

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    • "Patients who developed metastatic disease in a shorter time than the median metastasis-free survival (10 months) had statistically significantly worse sarcoma-specific survival than patients who developed metastatic disease after the median metastasis-free interval. That longer disease-free interval is associated with improved survival has also been reported by Harting et al. (2006). This suggests that there should be more frequent followup at the beginning, in order to detect and aggressively treat distant disease. "
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    ABSTRACT: There have only been a few nationwide studies on the epidemiology and outcome of osteosarcoma. We report the clinical features, treatment, and prognosis of osteosarcoma in Finland for the period 1971-1990. The study material was derived from population-based data from the national Finnish Cancer Registry. 302 osteosarcomas were reported during the study period. Histological slides could be retrieved for 199 cases and from histological re-examination, 139 (83%) of these cases were confirmed as osteosarcoma and were included in the analysis. The mean length of follow-up was 8 (0.1-28) years. The overall 5-year survival for the whole study population was 58%, with an improvement in survival during 1981-1990 (65%) compared to the period 1971-1980 (47%) (p=0.01). More chemotherapy was administered in the later time period. For metastasis-free survival, diagnosis in the 1970s as opposed to the 1980s (p=0.01) and large tumor size worsened outcome in univariate analysis. Patients who developed metastatic relapse within 10 months of the diagnosis had worse sarcoma-specific survival than those who developed metastases later. Limb-salvage surgery increased from 12% to 23% for patients with a peripheral tumor, with no increase in local relapses. We recommend aggressive approach to treat recurrent disease, with a view to further improving survival. In a small country such as Finland it is necessary to concentrate treatment to only a few centers, to ensure a high quality of treatment.
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    ABSTRACT: Background: Although presence of pulmonary metastasis is indicative of disease progression and its untreatable nature, in recent decades, numerous efforts have been made for treatment of these patients by surgical resection of metastatic lesions. The efficacy of this procedure has been variable in various reports and different diseases. This study aimed to evaluate the effect of metastatectomy in survival rate of patients with pulmonary metastases who underwent metastatectomy in Masih Daneshvari hospital. Materials and Methods: This was a retrospective study and we evaluated medical records of 99 patients suffering pulmonary metastasis who had been referred to our center during 1995-2007; out of which 48 patients who were qualified for metastatectomy underwent this operation. The required qualifications for surgery included: feasibility of resecting all metastatic lesions, tolerance of surgery by the patient, absence of metastatic lesions in organs other than the lungs, and control of primary disease. Information regarding the site of primary lesion and its pathology, time interval between the diagnosis of primary disease and metastasis, surgical morbidity and mortality, form of surgical procedure, type of incision, number of pulmonary metastases and survival rate of patients was collected. Patients were followed up via clinical visits. In case of insufficient clinical visits, we contacted the patient or his/her family and collected the rewired data. Obtained data were analyzed using SPSS software. To assess the patients' survival rate after the operation, Kaplan-Meier test was used. Results: Sixty-seven pulmonary metastatectomies were conducted on 48 patients (31 males and 17 females) in the age range of 16-86 years (mean 40 yrs). Twenty-five patients had unilateral and 23 had bilateral metastases. Among patients with bilateral metastases, 7 underwent single-phase metastatectomy while 16 underwent two or multi-phase metastatectomy. Surgical incisions were done through the following approaches: in 60 cases through postero-lateral thoracotomy, in 4 cases through mid-sternotomy and in 3 cases through bilateral anterior-transverse thoracotomy along with sternotomy (clamshell). In 61 cases pulmonary metastatic lesion was removed by wedge resection, in 14 cases by lobectomy and in one case by pneumonectomy. Mean number of resected lesions was 6.7 (range 1 to 59). Post- operative complications occurred in 10 patients (15%) including pneumothorax in 9 cases and chylothorax in one. No morbidity, mortality or life-threatening complications occurred in any of the patients. The mean survival of patients following metastatectomy was 22 months (range 1 to 128 months) and their 5-year survival was 24.5% Five patients had 5 years (60 months) or more survival. Conclusion: Although the under-study population was not homogenous pathologically, it seems that metastatectomy with acceptable morbidity, increases the survival of patients and in some cases results in their complete recovery. (Tanaffos 2008; 7(1): 47-51)
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