Osteosarcoma and pulmonary metastases: 15-year experience from a single institution

[Pleuropulmonary metastases originating from extra-thoracic neoplasia]

Les poumons reçoivent la totalité du drainage veineux du corps expliquant la grande fréquence des métastases pleuro-pulmonaires de plusieurs cancers. L'objectif était d'étudier les manifestations radio-cliniques des métastases pleuro-pulmonaires des cancers extra-thoraciques. Nous rapportons une étude rétrospective de patients porteurs de métastase pleuro-pulmonaire colligés dans notre service entre janvier 2006 et décembre 2014. 76 dossiers ont été étudiés. La moyenne d'âge était de 50 ans (extrêmes allant de 21 ans jusqu'à 89 ans) avec une prédominance masculine dans 57,8% des cas. La symptomatologie clinique était faite principalement de toux (32,8% des cas), de dyspnée (23,7% des cas) et d'hémoptysie (11,2% des cas). Les cancers primitifs à l'origine des différentes métastases pleuro-pulmonaires retrouvés dans notre série sont dominés respectivement par le cancer du sein dans 27,6% des cas, les cancers digestifs dans 15,8% des cas, les cancers génitaux dans 9,2% des cas, les sarcomes dans 7,8% des cas, le cancer rénal dans 5,2% des cas, le cancer de la vessie dans 5,2% des cas, le cancer de la prostate dans 3,9% cas, les cancers ORL dans 3,9% des cas, les cancers thyroïdiens dans 3,9% des cas, le cancer de la peau dans 2,6% des cas et le cancer primitif d'origine indéterminée dans 14,4% des cas. Plusieurs aspects radiologiques des métastases pleuro-pulmonaires ont été retrouvés dans notre série, ils peuvent être isolés ou en association. L'aspect radiologique le plus fréquent est celui du lâcher de ballon présent dans 52,6% des cas, suivi des pleurésies présentes dans 34,2% des cas, des micronodules diffus présents dans 23,6% des cas et un nodule unique présent dans 3,94% des cas. Les cancers secondaires pleuro-pulmonaires sont fréquents. Ils viennent en 3^ème position après les métastases ganglionnaires et hépatiques et ils sont retrouvés dans 30% des autopsies de patients porteurs d'une néoplasie.

Prevalence of Metastasis at Diagnosis of Osteosarcoma: An International Comparison

BACKGROUND

Osteosarcoma (OS) is the most common primary malignant bone tumor in many countries, with metastatic disease responsible for most patient deaths. This study compares the prevalence of metastatic OS at diagnosis across countries to inform the critical question of whether diagnostic delay or tumor biology drives metastases development prior to diagnosis.

PROCEDURE

A literature search of the PubMed database was conducted to compare the prevalence of metastatic disease at the time of OS diagnosis between countries. A pooled prevalence with 95% confidence intervals was calculated for each study meeting inclusion criteria. Studies were grouped for analysis based on human development index (HDI) scores.

RESULTS

Our analysis found an 18% (95% confidence interval [CI]: 15%, 20%) average global pooled proportion of metastasis at OS diagnosis. The average prevalence of metastasis at diagnosis increased as HDI groupings decreased, with very high HDI, high HDI, and medium/low HDI groups found to be 15% (95% CI: 13%, 17%), 20% (95% CI: 14%, 28%), and 31% (95% CI: 15%, 52%), respectively.

CONCLUSIONS

Our evidence suggests there is a biological baseline for metastatic OS at diagnosis, which is observed in countries with very high HDI. In countries with medium/low HDI, where there are more barriers to accessing healthcare, the higher prevalence of metastasis may result from treatment delay or an artificial prevalence inflation due to patients with less severe symptoms not presenting to clinic. Additional research in countries with medium/low HDI may reveal that earlier detection and treatment could improve patient outcomes in those countries.

Review of management issues in relapsed osteosarcoma

Osteosarcoma is the most common primary malignant bone tumor in children and adolescents. With combined modality treatment long-term survival rate for localized disease is near 70%. Thirty percent of patients relapse with lung as the commonest site. Surgery is the treatment of choice for relapsed patients whenever possible. Addition of chemotherapy to surgery provides survival benefit in patients not achieving second surgical remission. Even patients with multiple lung recurrences can be cured with repeated thoracotomies. Disease-free interval and complete surgical resection are the main prognostic factor for post-relapse survival.

[Recurrent spontaneous pneumothorax complicating osteosarcoma pulmonary metastasis]

We report the case of a 15-year-old girl with osteosarcoma in the left distal femur who developed a recurrent spontaneous pneumothorax. The patient was treated by neoadjuvant chemotherapy followed by surgery (limb-sparing surgical procedure with insertion of a knee prosthesis) and then adjuvant chemotherapy. The initial extension assessment was normal. No pulmonary metastasis was found. The chest tomography performed at the end of treatment (8 months after surgery) revealed two peripheral pulmonary nodules not seen on the chest X-ray. Palliative chemotherapy was given, the thoracic tomography after four chemotherapy courses showed a progress of the pulmonary metastasis and on the right more abundant bilateral pneumothorax which had recurred two months after thoracic draining. Thoracoscopy showed no pleural lesions.

Surgical management and outcome of osteosarcoma patients with unilateral pulmonary metastases

PURPOSE

The surgical management of osteosarcoma patients with unilateral pulmonary nodules is controversial. The authors reviewed their institutional experience to evaluate the incidence of occult contralateral metastases.

METHODS

Data were obtained retrospectively on all consecutive osteosarcoma patients from 1980 to 2002. Eighty-four patients with pulmonary nodules were identified. Forty-one had bilateral disease, and 43 had unilateral involvement by computed tomography (CT) scan.

RESULTS

All 43 patients with unilateral nodules underwent ipsilateral thoracotomies. Fifteen patients had negative exploration findings, and only 1 had pulmonary relapse. Of the 28 patients with metastases confirmed at initial thoracotomies, 14 had extensive pleural or extrapulmonary disease at initial thoracotomy followed by disease progression. The other 14 are separated into early versus late metastases, using 2 years from diagnosis as the cutoff point. Seven of the 9 (78%) patients with early metastases had or subsequently had contralateral disease; 6 were identified at staged contralateral thoracotomy and 1 had relapsed in the unexplored lung a year later. Only 1 of the 5 patients with late unilateral metastases had relapse in the contralateral side.

CONCLUSIONS

Our data indicate that there is a high rate of contralateral involvement in osteosarcoma patients with unilateral nodules diagnosed by CT scan. Staged bilateral thoracotomies should be considered in osteosarcoma patients presenting with unilateral pulmonary disease on imaging studies within 2 years of diagnosis.

Pattern of disease recurrence and prognostic factors in patients with osteosarcoma treated with contemporary chemotherapy

BACKGROUND

The goal of the current study was to define the clinical features and outcome of recurrent osteosarcoma (OS) in children and young adults initially treated with contemporary chemotherapy.

METHODS

The authors reviewed the clinical features, therapy, and outcome for 59 patients from the Mayo Clinic (Rochester, MN) and Children's Hospital and Regional Medical Center (Seattle, WA). They were diagnosed initially with OS between January 1990 and December 2000, received multiagent chemotherapy (most frequently cisplatin, doxorubicin, high-dose methotrexate, and ifosfamide), and developed disease recurrence after achieving an initial complete response (CR).

RESULTS

The most common site of initial disease recurrence was the lung only (n = 36 patients), followed by distant bone (n =8 patients), combined lung and other sites (n =7 patients), and other sites (n =8 patients). The median time to first disease recurrence was 15 months (range, 2-92 months) from the initial diagnosis. Thirty patients with isolated pulmonary recurrence achieved a second CR, either with surgery alone (n =15 patients) or surgery and salvage chemotherapy (n =15 patients). For this group, the 4-year disease-free survival (DFS) and overall survival rates were 7% (95% confidence interval [95% CI], 0-16%) and 28% (95% CI, 11-45%), respectively. For all 59 patients with recurrent OS, the 4-year DFS and overall survival rates were 6% (95% CI, 0-12%) and 23% (95% CI, 10-36%), respectively. The only factors associated with improved DFS and overall survival rates were unilateral pulmonary recurrence, solitary pulmonary nodule at recurrence, more than 24 months between the initial diagnosis and first disease recurrence, and achievement of a second CR.

CONCLUSIONS

The DFS and overall survival rates for recurrent OS after contemporary therapy remained poor even for patients with isolated pulmonary recurrence. Therefore, new treatment strategies are needed.

Surgical treatment of hepatic and pulmonary metastases from non-colorectal and non-neuroendocrine carcinoma

BACKGROUND

Surgical resection is standard treatment for colorectal and neuroendocrine liver metases provided the tumor can be removed completely. The same is true for isolated pulmonary metastases. To date, only few reports have addressed the value of surgical resection of organ metastases from other solid tumors.

METHODS

The literature was searched by Medline, conference proceedings and cross-referencing of published articles for information pertaining to the long-term results of surgical treatment of non-colorectal and non-neuroendocrine (NCNN) liver or lung metastases.

RESULTS

Resection of hepatic and pulmonary metastases is increasingly performed in non-colorectal and non-neuroendocrine malignancies. Mortality and morbidity of hepatic and pulmonary resection are low and 5 year survival can be expected to reach some 20-30 percent, irrespective of the histological type of the primary tumor.

CONCLUSION

Resection of hepatic or pulmonary metastasis should be considered in all patients with low operative risk provided that complete resection is possible.

Results of treatment for metastatic osteosarcoma with neoadjuvant chemotherapy and surgery

The purpose of the current study was to define the survival outcome variables for the 85 patients with Stage IIB osteosarcoma treated with neoadjuvant chemotherapy at the authors' institution from 1982 to 1997. A minimum 4-year followup or death was a requisite for inclusion. Forty-three patients were relapse-free survivors and 14 had no evidence of disease at followup for an overall survival of 67%. Twenty-nine patients had thoracotomy and nine have no evidence of disease with a minimum 4-year followup from last thoracotomy. The mean time to metastasis after diagnosis for patients presenting with Stage IIB disease was 12.8 months. There was no difference in the survival for any of the three chemotherapy protocols, used during the 15 years included in this analysis. There was a significant relation between length of time to relapse and survival. For each additional year without relapse, there is an 18% increase in chance of survival. In patients who were treated with thoracotomy, the number of metastatic nodules was a significant predictor of survival; specifically, each nodule increased the risk of death by 43%. A favorable outcome in this cohort of patients is related to the length of time between initiation of therapy and diagnosis of metastasis, and the number of metastatic foci.

Unusual cause of recurrent pneumothorax: excavated metastasis of osteosarcoma

We report the case of a recurrent right pneumothorax, revealing metastasis of an osteosarcoma, 40 months after complete remission. Seven years after surgical excision, the patient is still considered in complete remission. Pneumothorax is rarely the first manifestation of lung metastasis. Osteosarcoma is the most frequent primary tumor. Chest computed tomography detects excavated or subpleural lung metastasis. Differential diagnosis between benign and malignant bullous lesions is important because surgical excision affects survival in some malignancies.

Current treatment of osteosarcoma

A comprehensive multidisciplinary approach has transformed osteosarcoma from a disease with a modest long-term survival to one in which at least two-thirds of patients will be cured. Surgery remains the vital modality for treating the primary tumor, whereas adjuvant chemotherapy plays an essential role in the control of subclinical metastatic disease. Complete surgical excision of the primary tumor remains an essential element of treatment. For many patients, a combination of advances in surgical technique, improved imaging modalities to accurately document tumor extent, and the effect of neoadjuvant chemotherapy has made limb salvage procedures a safe alternative to amputation. In some patients for whom complete surgical excision is impossible, the addition of radiation therapy may allow local tumor control. The most effective chemotherapy agents currently in use include high-dose methotrexate, doxorubicin, cisplatin, and ifosfamide/etoposide. The optimal schedule of therapy is still being investigated, as is the role of dose intensification. Unfortunately, some groups of patients remain at high risk of eventual relapse. Those whose tumors show relatively low degrees of necrosis after administration of chemotherapy have poorer survival than patients with more chemotherapy-responsive tumors. Similarly, patients who present with overt metastatic disease (particularly bone metastases), as well as patients with tumors that recur after treatment, continue to have an unsatisfactory outcome. These groups, in particular, may benefit from future investigations into novel agents, such as biological response modifiers, antiangiogenesis factors, and growth receptor modulation.