Treatment Options for Lung-Only Metastases at Diagnosis

Treatment options for patients with metastatic lung lesions at diagnosis include the following:

Patients with metastatic lung lesions as the sole site of metastatic disease should have the lung lesions resected if possible. Generally, this is performed after the administration of preoperative chemotherapy. After definitive surgical resection of the primary tumor, most clinicians resume systemic chemotherapy before initiating lung surgery to avoid longer delays in the resumption of chemotherapy. In approximately 10% of patients, all lung lesions disappear after preoperative chemotherapy.[3] Complete resection of pulmonary metastatic disease can be achieved in a high percentage of patients with residual lung nodules after preoperative chemotherapy. The long-term survival is poor for patients who do not undergo complete surgical resection of pulmonary metastatic disease.[8,9][Level of evidence B4]

For patients who present with primary osteosarcoma and metastases limited to the lungs and who achieve complete surgical remission, the 5-year EFS rate is approximately 20% to 25%. Multiple metastatic nodules confer a worse prognosis than do one or two nodules, and bilateral lung involvement is worse than unilateral.[1] Patients with peripheral lung lesions may have a better prognosis than patients with central lesions.[10] Patients with fewer than three nodules confined to one lung may achieve a 5-year EFS rate of approximately 40% to 50%.[1]

A multi-institutional retrospective analysis compared thoracotomy with thoracoscopy for resection of pulmonary metastases in patients with osteosarcoma.[11] The analysis included patients who had pulmonary metastases at diagnosis, patients with pulmonary relapse after initial management of localized disease, and patients with disease progression while on therapy. The authors recognized a significant selection bias for the patients chosen to undergo thoracoscopy. In a Cox regression analysis, controlling for other factors impacting outcome, there was a significantly increased risk of mortality (hazard ratio [HR], 2.11; 95% CI, 1.09–4.09; P = .027) but not pulmonary recurrence (HR, 0.96; 95% CI, 0.52–1.79; P = .90) with a thoracoscopic approach. In a subset analysis limited to patients with oligometastatic disease, thoracoscopy did not increase the risk of mortality (HR, 1.16; 95% CI, 0.64–2.11; P = .62). The ongoing randomized trial (AOST2031 [NCT05235165]) was designed to definitively address this question and the selection bias. This trial will compare the effect of thoracotomy with thoracoscopic surgery.