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Postoperative chemotherapy
Source: Osteosarcoma and Undifferentiated Pleomorphic Sarcoma of Bone Treatment (PDQ®)–Health Professional Version, National Cancer Institute.
Source updated: December 2, 2024 · Captured 2026-09-09.
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Historically, the extent of tumor necrosis was used in some clinical trials to determine what type of postoperative chemotherapy would be given. In general, if tumor necrosis exceeded 90%, the preoperative chemotherapy regimen was continued. If tumor necrosis was less than 90%, some groups incorporated drugs not previously used in the preoperative therapy.
Patients with less necrosis after initial chemotherapy have an inferior prognosis than patients with more necrosis. The prognosis is still substantially better than the prognosis for patients treated with surgery alone and no adjuvant chemotherapy.
Based on the following evidence, it is inappropriate to conclude that patients with less necrosis have not responded to chemotherapy and that adjuvant chemotherapy should be withheld for these patients. Chemotherapy after definitive surgery should include the agents used in the initial phase of treatment unless there is clear and unequivocal progressive disease during the initial phase of therapy.
Evidence (using the same agents for postoperative chemotherapy):
Early reports from the Memorial Sloan Kettering Cancer Center (MSKCC) suggested that adding cisplatin to postoperative chemotherapy improved the outcome for patients with less than 90% tumor necrosis.[36]
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Early reports from the Memorial Sloan Kettering Cancer Center (MSKCC) suggested that adding cisplatin to postoperative chemotherapy improved the outcome for patients with less than 90% tumor necrosis.[36]
With longer follow-up, the outcome for patients with less than 90% tumor necrosis treated at MSKCC was the same whether they did or did not receive cisplatin in the postoperative phase of treatment.[37]
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In an early experience, the German COSS performed a trial in which the chemotherapy regimen for patients with poor necrosis was changed after initial treatment.[38] The agents used before surgery were discontinued and other agents were substituted.
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In an early experience, the German COSS performed a trial in which the chemotherapy regimen for patients with poor necrosis was changed after initial treatment.[38] The agents used before surgery were discontinued and other agents were substituted.
The results were substantially poorer for these patients than for patients who continued to receive the same agents.
Subsequent trials performed by other groups failed to demonstrate improved EFS when drugs not included in the preoperative regimen (cisplatin) were added to postoperative therapy.[19,39]
A limited-institution pilot trial tested the strategy of discontinuing the agents used in the initial phase of therapy for patients with poorer necrosis. Postoperative therapy consisted of melphalan with autologous stem cell reconstitution.[40]
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A limited-institution pilot trial tested the strategy of discontinuing the agents used in the initial phase of therapy for patients with poorer necrosis. Postoperative therapy consisted of melphalan with autologous stem cell reconstitution.[40]
The 5-year EFS rate for this group was 28%, which was lower than the EFS rates observed in many large series in which agents were continued despite a lesser degree of necrosis.
The international EURAMOS group consortium was formed to conduct a large, prospective, randomized trial to help determine whether modifying the chemotherapy regimen on the basis of the degree of necrosis would improve EFS. All patients received initial therapy with cisplatin, doxorubicin, and high-dose methotrexate (MAP). Patients with more than 90% necrosis were randomly assigned to continue the same chemotherapy after surgery or to receive the same chemotherapy with the addition of interferon alpha-2b.[33][Level of evidence B1] In the same EURAMOS trial, patients with less than 90% necrosis were randomly assigned to continue the same chemotherapy or to receive the same chemotherapy with the addition of high-dose ifosfamide and etoposide (MAPIE).[34][Level of evidence B1]
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The international EURAMOS group consortium was formed to conduct a large, prospective, randomized trial to help determine whether modifying the chemotherapy regimen on the basis of the degree of necrosis would improve EFS. All patients received initial therapy with cisplatin, doxorubicin, and high-dose methotrexate (MAP). Patients with more than 90% necrosis were randomly assigned to continue the same chemotherapy after surgery or to receive the same chemotherapy with the addition of interferon alpha-2b.[33][Level of evidence B1] In the same EURAMOS trial, patients with less than 90% necrosis were randomly assigned to continue the same chemotherapy or to receive the same chemotherapy with the addition of high-dose ifosfamide and etoposide (MAPIE).[34][Level of evidence B1]
The addition of interferon alpha-2b did not improve the probability of EFS.
The international EURAMOS group consortium was formed to conduct a large, prospective, randomized trial to help determine whether modifying the chemotherapy regimen on the basis of the degree of necrosis would improve EFS. All patients received initial therapy with cisplatin, doxorubicin, and high-dose methotrexate (MAP). Patients with more than 90% necrosis were randomly assigned to continue the same chemotherapy after surgery or to receive the same chemotherapy with the addition of interferon alpha-2b.[33][Level of evidence B1] In the same EURAMOS trial, patients with less than 90% necrosis were randomly assigned to continue the same chemotherapy or to receive the same chemotherapy with the addition of high-dose ifosfamide and etoposide (MAPIE).[34][Level of evidence B1]
With a median follow-up of over 61 months, the EFS did not differ between the two groups.
The international EURAMOS group consortium was formed to conduct a large, prospective, randomized trial to help determine whether modifying the chemotherapy regimen on the basis of the degree of necrosis would improve EFS. All patients received initial therapy with cisplatin, doxorubicin, and high-dose methotrexate (MAP). Patients with more than 90% necrosis were randomly assigned to continue the same chemotherapy after surgery or to receive the same chemotherapy with the addition of interferon alpha-2b.[33][Level of evidence B1] In the same EURAMOS trial, patients with less than 90% necrosis were randomly assigned to continue the same chemotherapy or to receive the same chemotherapy with the addition of high-dose ifosfamide and etoposide (MAPIE).[34][Level of evidence B1]
The intensification of treatment in the MAPIE group resulted in greater toxicity than did the treatment in the standard MAP arm.
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Preserved source evidence · Not medical advice