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Year : 2020  |  Volume : 57  |  Issue : 2  |  Page : 121--122

Pulmonary metastasectomy in osteosarcoma: Finite disappointments to keep alive the infinite hope!

Avinash Pande1, Jyoti Bajpai2,  
1 Department of Medical Oncology, State Cancer Center, Indira Gandhi Institute of Medical Sciences (IGIMS) Patna, Mumbai, Maharashtra, India
2 Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India

Correspondence Address:
Jyoti Bajpai
Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra
India




How to cite this article:
Pande A, Bajpai J. Pulmonary metastasectomy in osteosarcoma: Finite disappointments to keep alive the infinite hope!.Indian J Cancer 2020;57:121-122


How to cite this URL:
Pande A, Bajpai J. Pulmonary metastasectomy in osteosarcoma: Finite disappointments to keep alive the infinite hope!. Indian J Cancer [serial online] 2020 [cited 2020 May 31 ];57:121-122
Available from: http://www.indianjcancer.com/text.asp?2020/57/2/121/284483


Full Text



Osteosarcoma is the most common primary bone malignancy in adolescents. Although multimodality therapy has improved survival of non-metastatic osteosarcomas, it is still associated with gloomy prognosis.[1]

In general, a quarter of patients diagnosed with osteosarcoma present with de-novo metastasis and an additional 30–40% patients develop metastasis at the relapse after adjuvant treatment.[2],[3] Majority (80%) of the synchronous and metachronous metastases are confined to lung and pulmonary metastasectomy is a well-established management approach for these.[2]

Since bone sarcoma patients are young, with relatively preserved organ functions, they can withstand pulmonary metastasectomy in a much better way. There is a fair chance of longer metastasis-free interval and improved life expectancy with this aggressive approach.[2],[3]

As in any rare disease, conducting randomised trials is extremely difficult in metastatic osteosarcomas. There are potential confounders including heterogeneity in nature and volume of pulmonary metastasis, disease free interval, prior systemic therapy compliance and response, surgical expertise and infrastructure limitations.[4],[5] Besides, there is a dearth of high-quality evidence-based guidelines to help clinicians in the decision-making process.

Despite this shortcoming, several retrospective case series and registry data consistently suggest prolonged survival for patients who underwent pulmonary metastasectomy in osteosarcoma. Thames Registry is one of the largest systematic reviews, wherein 1351 pulmonary metastasectomies were done in specialist thoracic centres and the patients were rigorously followed up for 18 years. It demonstrated impressive five-year survival of 35% after the first metastasectomy with a trend to improved survival with each passing decade.[4] This was attributed to better case selection, aggressive approach, maturing of a learning curve and enhanced surgical skills. Many of these patients had incidentally detected metastasis on surveillance scans which highlights the advantage of picking the metastasis early via enhanced follow-up with computerised tomography (CT) scans of the chest.[4] However, one must remember that CT scans often underestimate the number and extent of lung metastasis. Notably, most of the surgeons performed open thoracotomies with manual palpation and visceral visualisation of metastasis, which increased the yield compared to exclusive video-assisted thoracoscopic approach.

In the current issue of Indian Journal of Cancer, Ramanujan V, et al. present a retrospective case series of 37 osteosarcomas who underwent pulmonary metastasectomy over 15 years.[5] Majority of patients (54%) were relatively good prognostic as they had only single pulmonary metastases. Post-chemotherapy, 77% had a poor response and post metastectomy, 19% of them received second-line chemotherapy with 20% survival at 5 years. The largest published series in India is from Tata Memorial Hospital, Mumbai wherein 80 patients with metastatic osteosarcomas were treated prospectively with a novel, “OGS-12 ” protocol. This dose-dense protocol comprises of three active drugs (cisplatinum, adriamycin and ifosfamide) and administered in neo (adjuvant) fashion as sequential doublets.[3] The patients who received aggressive multimodality therapy had 27% four-year survival. Interestingly, 25% of patients who were event-free for 30 months had prolonged survival, which emphasised the importance of aggressive multimodality approach in this select subgroup of patients.[3]

There is evidence from the literature that improved outcomes have been demonstrated with multiple revision pulmonary metastasectomies, however, there might also be a selection bias with preferential picking of good biology-disease for repeated surgeries.[4],[6]

Therefore, it is incumbent on treating oncologists to select the patients who have the potential to derive maximum benefit without significant complications that may require prolonged rehabilitation.

Stringent selection criteria including controlled primary disease, potential complete resectability of pulmonary and (limited) extrapulmonary metastases, adequate pulmonary reserve and good performance status of the patient might help in achieving better therapeutic index with best outcomes. The good biology of the disease dominates all across with good histological responders and longer disease-free interval (>1 year) following systemic therapy had the best outcomes.[4],[6],[7]

Aggressive multimodality approach with multiagent chemotherapy, optimal limb surgery and pulmonary metastasectomy is the preferred therapeutic option for osteosarcoma with pulmonary metastasis. Meticulous case selection to look for the important prognostic indicators in this subgroup along with adequate surgical expertise and infrastructure are prerequisites to achieve the best outcomes and possibility of a cure in this select subgroup of the patients. It is thus justified to accept finite disappointments to keep alive the infinite hope!

References

1Bajpai J, Chandrasekharan A, Talreja V, Simha V, Chandrakanth MV, Rekhi B. Outcomes in non-metastatic treatment naive extremity osteosarcoma patients treated with a novel non-high dosemethotrexate-based, dose-dense combination chemotherapy regimen 'OGS-12. Eur J Cancer 2017;85:49-58.
2Aljubran AH, Griffin A, Pintilie M, Blackstein M. Osteosarcoma in adolescents and adults: Survival analysis with and without lung metastases. Ann Oncol 2009;20:1136-41.
3Bajpai J, Chandrasekharan A, Simha V, Talreja V, Karpe A, Pandey N, et al. Outcomes in treatment-naïve patients with metastatic extremity osteosarcoma treated with OGS-12, a novel non–high-dose methotrexate–based, dose-dense combination chemotherapy, in a Tertiary care cancer center. J Glob Oncol 2018;4:1-10.
4Treasure T, Fiorentino F, Scarci M, Møller H, Utley M. Pulmonary metastasectomy for sarcoma: A systematic review of reported outcomes in the context of Thames cancer registry data. BMJ Open 2012;2:e001736.
5Ramanujan V, Krishnamurthy A, Venkataramani K, Kumar C. Pulmonary metastasectomy in primary extremity osteosarcoma: Choosing wisely, along with a brief review of literature. Indian J Cancer 2020;57:172-81.
6Khanna N, Pandey A, Bajpai J. Metastatic Ewing's sarcoma: Revisiting the “Evidence on the fence ”. Indian J Med Paediatr Oncol 2017;38:173.
7Kim S, Ott HC, Wright CD, Wain JC, Morse C, Gaissert HA, et al. Pulmonary resection of metastatic sarcoma: Prognostic factors associated with improved outcomes. Ann Thorac Surg 2011;92:1780-6.